Provider Demographics
NPI:1720046857
Name:HAVRILIAK, DAMIAN J (MD)
Entity Type:Individual
Prefix:
First Name:DAMIAN
Middle Name:J
Last Name:HAVRILIAK
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 1:2 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4164
Mailing Address - Country:US
Mailing Address - Phone:845-357-6202
Mailing Address - Fax:845-357-6239
Practice Address - Street 1:2 EXECUTIVE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4164
Practice Address - Country:US
Practice Address - Phone:845-357-6202
Practice Address - Fax:845-357-6239
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2008-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY175798208200000X
NJ25MA0638500208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39L051Medicare ID - Type Unspecified
NJ016283Medicare ID - Type Unspecified
G79316Medicare UPIN