Provider Demographics
NPI:1265483481
Name:FACTOUROVICH, ALEXANDER YAKOV (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:YAKOV
Last Name:FACTOUROVICH
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 1:43 SAN MARCO DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-5017
Mailing Address - Country:US
Mailing Address - Phone:607-729-7955
Mailing Address - Fax:607-729-7955
Practice Address - Street 1:10-42 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1617
Practice Address - Country:US
Practice Address - Phone:607-762-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2331802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02601632Medicaid
I20958Medicare UPIN
NYRA4863Medicare PIN