Provider Demographics
NPI:1477651701
Name:KHACHADURIAN, VARTKES (MD)
Entity Type:Individual
Prefix:DR
First Name:VARTKES
Middle Name:
Last Name:KHACHADURIAN
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 1:72 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-2528
Mailing Address - Country:US
Mailing Address - Phone:516-354-2080
Mailing Address - Fax:516-354-0979
Practice Address - Street 1:72 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-2528
Practice Address - Country:US
Practice Address - Phone:516-354-2080
Practice Address - Fax:516-354-0979
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY916331Medicare PIN