Provider Demographics
NPI:1700979572
Name:BEZIRGANIAN, SOPHIA (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:BEZIRGANIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4135
Mailing Address - Country:US
Mailing Address - Phone:607-273-7494
Mailing Address - Fax:607-732-0373
Practice Address - Street 1:1003 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1007
Practice Address - Country:US
Practice Address - Phone:607-732-5646
Practice Address - Fax:607-732-0373
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1674632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01400417Medicaid
NYF44064Medicare UPIN
NY56696BMedicare ID - Type Unspecified