Provider Demographics
NPI:1659396422
Name:ISSEROFF, AVRAHAM Z (MD)
Entity Type:Individual
Prefix:
First Name:AVRAHAM
Middle Name:Z
Last Name:ISSEROFF
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 1:58 PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5425
Mailing Address - Country:US
Mailing Address - Phone:203-801-4331
Mailing Address - Fax:203-801-4331
Practice Address - Street 1:58 PINE ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5425
Practice Address - Country:US
Practice Address - Phone:203-801-4331
Practice Address - Fax:203-801-4331
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0436412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001436410Medicaid
CTD06413Medicare UPIN
CT260004416Medicare ID - Type Unspecified