Provider Demographics
NPI:1851697619
Name:GAVRIIL AGAON, M.D., P.C.
Entity Type:Organization
Organization Name:GAVRIIL AGAON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVRIIL
Authorized Official - Middle Name:
Authorized Official - Last Name:AGAON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-532-3131
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02243589Medicaid
NY05035OtherMEDICARE PROVIDER NUMBER
NY05035OtherMEDICARE PROVIDER NUMBER