Provider Demographics
NPI:1700931185
Name:MARTIROSOV, ALEKSANDR (DO)
Entity type:Individual
Prefix:
First Name:ALEKSANDR
Middle Name:
Last Name:MARTIROSOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31-00 BROADWAY
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3963
Mailing Address - Country:US
Mailing Address - Phone:201-791-7771
Mailing Address - Fax:201-791-7337
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-791-7771
Practice Address - Fax:201-791-7337
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06860100207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG65075Medicare UPIN
NJ026128R77Medicare ID - Type Unspecified