Provider Demographics
NPI:1992751366
Name:MARAVEGIAS, ISMENE N (MD)
Entity type:Individual
Prefix:
First Name:ISMENE
Middle Name:N
Last Name:MARAVEGIAS
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 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:400 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2602
Practice Address - Country:US
Practice Address - Phone:315-212-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217757207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY223594884OtherEXCELLUS BCBS
NY223594884008OtherCHAMPUS/TRICARE
NYJ400014931Medicare PIN
NY223594884OtherEXCELLUS BCBS
NY223594884008OtherCHAMPUS/TRICARE