Basic Information
| Provider Information | |||||||||
| NPI: | 1588751333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROUSTA | ||||||||
| FirstName: | MEHDI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 WEST 33RD STREET | ||||||||
| Address2: | PBS 12TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123564474 | ||||||||
| FaxNumber: | 2123564608 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 BARD AVE | ||||||||
| Address2: | SURGERY | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188166440 | ||||||||
| FaxNumber: | 7188163611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 125645 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00249261 | 05 | NC | MEDICAID |