Provider Demographics
NPI:1154653293
Name:VAYSBAUM, IGOR (RPH)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:VAYSBAUM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE #12
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-9003
Mailing Address - Country:US
Mailing Address - Phone:718-257-8777
Mailing Address - Fax:718-257-8884
Practice Address - Street 1:1110 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE #12
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9003
Practice Address - Country:US
Practice Address - Phone:718-257-8777
Practice Address - Fax:718-257-8884
Is Sole Proprietor?:No
Enumeration Date:2010-01-30
Last Update Date:2010-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist