Provider Demographics
NPI:1699743906
Name:PANOSSIAN, ALEXANDER M (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:M
Last Name:PANOSSIAN
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 1:204 HEMPSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4810
Mailing Address - Country:US
Mailing Address - Phone:201-447-6117
Mailing Address - Fax:201-447-3638
Practice Address - Street 1:230 E RIDGEWOOD AVE
Practice Address - Street 2:#6-204
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-4131
Practice Address - Country:US
Practice Address - Phone:201-447-6117
Practice Address - Fax:201-447-3638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03259000208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA03259000OtherLICENSE
NJ4721900Medicaid
NJ25MA03259000OtherLICENSE
NJB12666Medicare UPIN