Provider Demographics
NPI:1063496768
Name:KOOHSARI, HADI (MD)
Entity Type:Individual
Prefix:
First Name:HADI
Middle Name:
Last Name:KOOHSARI
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 1:701 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-1504
Mailing Address - Country:US
Mailing Address - Phone:518-374-1610
Mailing Address - Fax:518-374-3512
Practice Address - Street 1:701 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-1504
Practice Address - Country:US
Practice Address - Phone:518-374-1610
Practice Address - Fax:518-374-3512
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2086081208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00628079Medicaid