Provider Demographics
NPI:1235300096
Name:FARSHAD DAVID HANNANIAN M D P C
Entity Type:Organization
Organization Name:FARSHAD DAVID HANNANIAN M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FARSHAD
Authorized Official - Middle Name:D
Authorized Official - Last Name:HANNANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-773-3048
Mailing Address - Street 1:475 NORTHERN BLVD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4802
Mailing Address - Country:US
Mailing Address - Phone:516-773-3048
Mailing Address - Fax:516-304-5011
Practice Address - Street 1:475 NORTHERN BLVD
Practice Address - Street 2:SUITE 18
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4802
Practice Address - Country:US
Practice Address - Phone:516-773-3048
Practice Address - Fax:516-304-5011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213283174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01986709Medicaid
NY01986709Medicaid