Provider Demographics
NPI:1295797215
Name:AGARONIN, IGOR (MD)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:AGARONIN
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:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:908-522-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL15815207R00000X
NJ25MA07956400208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273862Medicaid
NJP00399303OtherRAIL ROAD MEDICARE
OR858463040OtherBCBS-MEDFORD
OR838334029OtherBCBS-ROSEBURG
OR858464029OtherBCBS-SPRINGFIELD
NJ095231TN1Medicare PIN
OR135408Medicare PIN
OR133626Medicare ID - Type Unspecified
OR838366037OtherBCBS-MCMINNVILLE
ORI43746Medicare UPIN
NJ817077000OtherBCBS