Provider Demographics
NPI:1831354513
Name:AGHALAR, MARYAM RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:RAFAEL
Last Name:AGHALAR
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 1:97-12 63RD DRIVE
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2445
Mailing Address - Country:US
Mailing Address - Phone:718-897-7430
Mailing Address - Fax:718-896-0062
Practice Address - Street 1:97-12 63RD DRIVE
Practice Address - Street 2:SUITE 1-B
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2445
Practice Address - Country:US
Practice Address - Phone:718-897-7430
Practice Address - Fax:718-896-0062
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263923208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation