Provider Demographics
NPI:1184677767
Name:DALAVAGAS, BASIL (M D)
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:DALAVAGAS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 UNIVERSITY PL
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4515
Mailing Address - Country:US
Mailing Address - Phone:212-604-1361
Mailing Address - Fax:212-604-1379
Practice Address - Street 1:95 UNIVERSITY PL
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4515
Practice Address - Country:US
Practice Address - Phone:212-604-1361
Practice Address - Fax:212-604-1379
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117409207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00507039Medicaid
NYB18688Medicare UPIN
NY00507039Medicaid