Provider Demographics
NPI:1134509615
Name:AVON MEDICAL WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:AVON MEDICAL WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGIV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-272-4646
Mailing Address - Street 1:540 HOPMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2496
Mailing Address - Country:US
Mailing Address - Phone:860-272-4646
Mailing Address - Fax:860-272-4642
Practice Address - Street 1:540 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-2496
Practice Address - Country:US
Practice Address - Phone:860-272-4646
Practice Address - Fax:860-272-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047333207RC0000X
CT001816363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGMedicaid
CT047333OtherSTATE LICENSE
CTPENDINGMedicaid