Basic Information
| Provider Information | |||||||||
| NPI: | 1205896800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHANDKER | ||||||||
| FirstName: | FERDOUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7017 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113723922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185655600 | ||||||||
| FaxNumber: | 7185655686 | ||||||||
| Practice Location | |||||||||
| Address1: | 7017 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113723922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185655600 | ||||||||
| FaxNumber: | 7185655686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 225253 | NY | Y | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02300407 | 05 | NY | MEDICAID |