Provider Demographics
NPI:1508280686
Name:MAVROUDIS, GINA (MASTERS)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MAVROUDIS
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 80TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-2711
Mailing Address - Country:US
Mailing Address - Phone:917-559-7999
Mailing Address - Fax:
Practice Address - Street 1:7616 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2412
Practice Address - Country:US
Practice Address - Phone:718-921-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY121787354Medicaid