Provider Demographics
NPI:1871738617
Name:ISMAILOV, AVNER
Entity type:Individual
Prefix:DR
First Name:AVNER
Middle Name:
Last Name:ISMAILOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 NATIONAL ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2321
Mailing Address - Country:US
Mailing Address - Phone:718-507-0442
Mailing Address - Fax:
Practice Address - Street 1:4016 NATIONAL ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2321
Practice Address - Country:US
Practice Address - Phone:718-507-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY52755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist