Provider Demographics
NPI:1134560121
Name:MALTZ, AVERY H
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:H
Last Name:MALTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22071 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2637
Mailing Address - Country:US
Mailing Address - Phone:718-631-1698
Mailing Address - Fax:
Practice Address - Street 1:24302 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362-1150
Practice Address - Country:US
Practice Address - Phone:718-423-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program