Provider Demographics
NPI:1962407627
Name:AJEMIAN, GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:AJEMIAN
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 1:1010 NORTHERN BLVD STE 328
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5329
Mailing Address - Country:US
Mailing Address - Phone:516-233-2484
Mailing Address - Fax:516-304-5850
Practice Address - Street 1:225 NASSAU BLVD # B
Practice Address - Street 2:
Practice Address - City:W HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2247
Practice Address - Country:US
Practice Address - Phone:516-775-9292
Practice Address - Fax:516-775-9294
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171659207R00000X
PAMD040599L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
15E521Medicare ID - Type Unspecified
A60784Medicare UPIN