Provider Demographics
NPI:1689828287
Name:AVE J MEDICAL PC
Entity type:Organization
Organization Name:AVE J MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:E
Authorized Official - Last Name:TAFLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-338-1166
Mailing Address - Street 1:4010 AVENUE J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4440
Mailing Address - Country:US
Mailing Address - Phone:718-338-1166
Mailing Address - Fax:718-951-7550
Practice Address - Street 1:4010 AVENUE J
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4440
Practice Address - Country:US
Practice Address - Phone:718-338-1166
Practice Address - Fax:718-951-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01906270Medicaid
NY33D0963294OtherCLIA #
NY212382OtherLICENSE
NYBT6238934OtherDEA
NY212382OtherLICENSE
NYG90658Medicare UPIN