Provider Demographics
NPI:1366457806
Name:IAVICOLI, LAURA G (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:IAVICOLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:ROOM A1-9
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-4952
Mailing Address - Fax:718-334-4815
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:ROOM A1-9
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-4952
Practice Address - Fax:718-334-4815
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211850207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02184292Medicaid
NY0025UYMedicare PIN
NYH49690Medicare UPIN