Basic Information
Provider Information
NPI: 1013498450
EntityType: 2
ReplacementNPI:  
OrganizationName: HOORBOD DELSHADFAR MEDICAL PC
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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
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AuthorizedOfficialLastName: DELSHADFAR
AuthorizedOfficialFirstName: HOORBOD
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AuthorizedOfficialTitleorPosition: OWNER/DO
AuthorizedOfficialTelephone: 6317758605
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: DO
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X244818NYY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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