Provider Demographics
NPI:1700312774
Name:NEW YORK ALLERGY ASTHMA & IMMUNOLOGY PC
Entity Type:Organization
Organization Name:NEW YORK ALLERGY ASTHMA & IMMUNOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AVSHALOMOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-444-8014
Mailing Address - Street 1:PO BOX 541
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-0541
Mailing Address - Country:US
Mailing Address - Phone:718-444-8014
Mailing Address - Fax:718-444-8068
Practice Address - Street 1:2084 E 67TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-6008
Practice Address - Country:US
Practice Address - Phone:718-444-8014
Practice Address - Fax:718-444-8068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02217114Medicaid
NY02217114Medicaid