Provider Demographics
NPI:1942328802
Name:GAFANOVICH, MARINA (MD)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GAFANOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-5970
Mailing Address - Country:US
Mailing Address - Phone:212-249-6218
Mailing Address - Fax:212-628-7059
Practice Address - Street 1:1550 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-5970
Practice Address - Country:US
Practice Address - Phone:212-249-6218
Practice Address - Fax:212-628-7059
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1290V1Medicare PIN