Provider Demographics
NPI:1225135197
Name:GORGISSIAN, HAGOP (MD)
Entity Type:Individual
Prefix:DR
First Name:HAGOP
Middle Name:
Last Name:GORGISSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6519 247TH ST
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2326
Mailing Address - Country:US
Mailing Address - Phone:917-733-3283
Mailing Address - Fax:
Practice Address - Street 1:11929 80TH RD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1105
Practice Address - Country:US
Practice Address - Phone:917-733-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2389732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid