Provider Demographics
NPI:1184674194
Name:KHODADADI, AYOOB (MD,)
Entity Type:Individual
Prefix:DR
First Name:AYOOB
Middle Name:
Last Name:KHODADADI
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 1:2678 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113253-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00717955Medicaid
NY07678GMedicare PIN
NY00717955Medicaid
NY644623Medicare PIN