Basic Information
Provider Information | |||||||||
NPI: | 1013498450 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOORBOD DELSHADFAR MEDICAL PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5 GRENWOLDE DR | ||||||||
Address2: |   | ||||||||
City: | GREAT NECK | ||||||||
State: | NY | ||||||||
PostalCode: | 110241616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5164820500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 287 NORTHERN BLVD STE 108 | ||||||||
Address2: |   | ||||||||
City: | GREAT NECK | ||||||||
State: | NY | ||||||||
PostalCode: | 110214717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5164820500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2018 | ||||||||
LastUpdateDate: | 08/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DELSHADFAR | ||||||||
AuthorizedOfficialFirstName: | HOORBOD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DO | ||||||||
AuthorizedOfficialTelephone: | 6317758605 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 244818 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.