Provider Demographics
NPI:1033616206
Name:GHEZELAIAGH, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:GHEZELAIAGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY BLDG 17C
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2563
Mailing Address - Country:US
Mailing Address - Phone:631-210-6305
Mailing Address - Fax:631-292-7376
Practice Address - Street 1:2500 NESCONSET HWY BLDG 17C
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2563
Practice Address - Country:US
Practice Address - Phone:631-210-6305
Practice Address - Fax:631-292-7376
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3129132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty