Provider Demographics
NPI:1780819557
Name:AVL PODIATRY PC
Entity Type:Organization
Organization Name:AVL PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDER
Authorized Official - Middle Name:VALENTINOVICH
Authorized Official - Last Name:LAVRENOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-687-7528
Mailing Address - Street 1:1401 ELM AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5945
Mailing Address - Country:US
Mailing Address - Phone:917-687-7528
Mailing Address - Fax:718-886-1413
Practice Address - Street 1:1401 ELM AVE
Practice Address - Street 2:SUITE D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5945
Practice Address - Country:US
Practice Address - Phone:191-768-7758
Practice Address - Fax:718-886-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006226213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6330200001Medicare NSC