Provider Demographics
NPI:1962586552
Name:DEVIAN HAZARIAN, DACIA (MD)
Entity type:Individual
Prefix:
First Name:DACIA
Middle Name:
Last Name:DEVIAN HAZARIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:29-15 FAR ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-337-7000
Practice Address - Fax:718-943-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02782745Medicaid
NY228655OtherSTATE LICENSE
NY02782745Medicaid