Provider Demographics
NPI:1053315044
Name:MARVASTI, MEHDI A (MD)
Entity Type:Individual
Prefix:
First Name:MEHDI
Middle Name:A
Last Name:MARVASTI
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 1:104 UNION AVE
Mailing Address - Street 2:SUITE 1008
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203
Mailing Address - Country:US
Mailing Address - Phone:315-422-4442
Mailing Address - Fax:315-448-6126
Practice Address - Street 1:104 UNION AVE
Practice Address - Street 2:SUITE 1008
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203
Practice Address - Country:US
Practice Address - Phone:315-422-4442
Practice Address - Fax:315-448-6126
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141551208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00683532Medicaid
NYJ400077869Medicare PIN
NY00683532Medicaid