Provider Demographics
NPI:1154570679
Name:VAEZI, ALEC EBRAIM (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ALEC
Middle Name:EBRAIM
Last Name:VAEZI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:120 MINEOLA BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4077
Mailing Address - Country:US
Mailing Address - Phone:516-663-2436
Mailing Address - Fax:516-663-2780
Practice Address - Street 1:120 MINEOLA BLVD STE 320
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4077
Practice Address - Country:US
Practice Address - Phone:516-663-2436
Practice Address - Fax:516-663-2780
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA105098207Y00000X
PAMT183380207Y00000X
NY301004207Y00000X
MA253792207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05858562Medicaid
MA110095099AMedicaid