Provider Demographics
NPI:1619134921
Name:HERMAN AYVAZYAN
Entity Type:Organization
Organization Name:HERMAN AYVAZYAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AYVAZYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-434-6464
Mailing Address - Street 1:450 VETERANS MEMORIAL PKWY # 12
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5300
Mailing Address - Country:US
Mailing Address - Phone:401-434-6464
Mailing Address - Fax:401-438-1890
Practice Address - Street 1:450 VETERANS MEMORIAL PKWY # 12
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5300
Practice Address - Country:US
Practice Address - Phone:401-434-6464
Practice Address - Fax:401-438-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI7061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9001194Medicaid
119001149Medicare PIN
RI9001194Medicaid