Basic Information
Provider Information | |||||||||
NPI: | 1417258344 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAHMOUDIANI | ||||||||
FirstName: | SHAHRIAR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MAHMOUDIANI | ||||||||
OtherFirstName: | SHAHRIAR | ||||||||
OtherMiddleName: | ABOLGHASEM | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 107 W 4TH ST | ||||||||
Address2: | ADMINISTRATION | ||||||||
City: | MOUNT VERNON | ||||||||
State: | NY | ||||||||
PostalCode: | 105504002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146997200 | ||||||||
FaxNumber: | 9146990837 | ||||||||
Practice Location | |||||||||
Address1: | 107 W 4TH ST | ||||||||
Address2: | ADMINISTRATION | ||||||||
City: | MOUNT VERNON | ||||||||
State: | NY | ||||||||
PostalCode: | 105504002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146997200 | ||||||||
FaxNumber: | 9146990837 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2010 | ||||||||
LastUpdateDate: | 06/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 255748 | NY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.