Provider Demographics
NPI:1851391692
Name:ISRAEL, IGOR (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:ISRAEL
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 1:9925 65TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3654
Mailing Address - Country:US
Mailing Address - Phone:718-459-6505
Mailing Address - Fax:718-459-4247
Practice Address - Street 1:11241 QUEENS BLVD
Practice Address - Street 2:SUITE LLB
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7475
Practice Address - Country:US
Practice Address - Phone:718-520-7723
Practice Address - Fax:718-520-7733
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02172223Medicaid
NYH41924Medicare UPIN
NY5P4741Medicare ID - Type Unspecified