Provider Demographics
NPI:1487654984
Name:AYVAZIAN, PHILIP J (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:AYVAZIAN
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 1:25 OAK AVENUE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-756-6293
Mailing Address - Fax:508-756-9404
Practice Address - Street 1:25 OAK AVENUE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-756-6293
Practice Address - Fax:508-756-9404
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74112208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA31175338Medicaid
MA3087255Medicaid
F14234Medicare UPIN
MA3087255Medicaid