Provider Demographics
NPI:1578965638
Name:MODERN GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:MODERN GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KONSTANTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-446-6839
Mailing Address - Street 1:947 79TH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-2613
Mailing Address - Country:US
Mailing Address - Phone:347-446-6839
Mailing Address - Fax:718-333-1023
Practice Address - Street 1:2705 MERMAID AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2005
Practice Address - Country:US
Practice Address - Phone:718-265-2222
Practice Address - Fax:718-333-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-20
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty