Provider Demographics
NPI:1306976097
Name:EGAZARIAN, MARC MESROB (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:MESROB
Last Name:EGAZARIAN
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 1:477 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-2803
Mailing Address - Country:US
Mailing Address - Phone:201-941-6999
Mailing Address - Fax:
Practice Address - Street 1:477 BERGEN BLVD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-2803
Practice Address - Country:US
Practice Address - Phone:201-941-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA64829208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH15411Medicare UPIN
NJ037754Medicare ID - Type Unspecified