Provider Demographics
NPI:1194380105
Name:PERSONALIZED CARDIAC CARE PC
Entity Type:Organization
Organization Name:PERSONALIZED CARDIAC CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ZAZA
Authorized Official - Middle Name:JOSUHUA
Authorized Official - Last Name:AIVAZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-454-4356
Mailing Address - Street 1:777 ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2937
Mailing Address - Country:US
Mailing Address - Phone:718-440-6161
Mailing Address - Fax:
Practice Address - Street 1:211 E 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0819
Practice Address - Country:US
Practice Address - Phone:212-879-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2491454Medicaid