Provider Demographics
NPI:1235366618
Name:AVSHALUMOV, MARAT (PHD)
Entity Type:Individual
Prefix:
First Name:MARAT
Middle Name:
Last Name:AVSHALUMOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MERRICK RD STE 128W
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4821
Mailing Address - Country:US
Mailing Address - Phone:516-255-9031
Mailing Address - Fax:516-255-6010
Practice Address - Street 1:100 MERRICK RD STE 128W
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4821
Practice Address - Country:US
Practice Address - Phone:516-255-9031
Practice Address - Fax:516-255-6010
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1462246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG