Provider Demographics
NPI:1326057548
Name:AVAGYAN, IGOR Z (MD)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:Z
Last Name:AVAGYAN
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 1:397 SKI TRL
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2247
Mailing Address - Country:US
Mailing Address - Phone:917-494-8226
Mailing Address - Fax:212-426-1409
Practice Address - Street 1:397 SKI TRL
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2247
Practice Address - Country:US
Practice Address - Phone:917-494-8226
Practice Address - Fax:212-426-1409
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2016-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218312207R00000X
NJ25MA07456200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02088017Medicaid
NY62C071Medicare ID - Type Unspecified
NY02088017Medicaid
NJ175359Medicare PIN