Basic Information
| Provider Information | |||||||||
| NPI: | 1497905293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONCHAROV | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 AXINN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115302139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 NOSTRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112054924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188265900 | ||||||||
| FaxNumber: | 7188265860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 250481 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 03100290 | 05 | NY | MEDICAID |