Provider Demographics
NPI:1699858506
Name:AGAON, GAVRIIL (MD)
Entity Type:Individual
Prefix:
First Name:GAVRIIL
Middle Name:
Last Name:AGAON
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 1:6715 102ND ST
Mailing Address - Street 2:APT - 7T
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2453
Mailing Address - Country:US
Mailing Address - Phone:718-275-3370
Mailing Address - Fax:
Practice Address - Street 1:9972 66TH RD
Practice Address - Street 2:SUITE - LH
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4460
Practice Address - Country:US
Practice Address - Phone:718-532-3131
Practice Address - Fax:718-997-8040
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02243589Medicaid
NYH56206Medicare UPIN
NY02243589Medicaid