Provider Demographics
NPI:1083664767
Name:A. KHODADADI RADIOLOGY P.C.
Entity Type:Organization
Organization Name:A. KHODADADI RADIOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AYOOB
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODADADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:718-333-0207
Mailing Address - Street 1:2678 GERRITSEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5947
Mailing Address - Country:US
Mailing Address - Phone:718-333-0275
Mailing Address - Fax:718-333-0224
Practice Address - Street 1:2678 GERRITSEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5947
Practice Address - Country:US
Practice Address - Phone:718-333-0275
Practice Address - Fax:718-333-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113253-1173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07678Medicare PIN
NYWHW211Medicare PIN