Provider Demographics
NPI:1578596045
Name:GRIGORIAN, ALEXANDRE (DO)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRE
Middle Name:
Last Name:GRIGORIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1120
Mailing Address - Country:US
Mailing Address - Phone:718-862-1100
Mailing Address - Fax:718-962-2268
Practice Address - Street 1:4014 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1120
Practice Address - Country:US
Practice Address - Phone:718-862-1100
Practice Address - Fax:718-962-2268
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02220895Medicaid
NY02220895Medicaid
NY5000GDW761Medicare ID - Type Unspecified