Provider Demographics
NPI:1265838254
Name:NYC INTERNAL MEDICINE DOCTOR, P.C.
Entity Type:Organization
Organization Name:NYC INTERNAL MEDICINE DOCTOR, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODADADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-313-8642
Mailing Address - Street 1:170 E 83RD ST
Mailing Address - Street 2:APT 2K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-1920
Mailing Address - Country:US
Mailing Address - Phone:516-313-8642
Mailing Address - Fax:
Practice Address - Street 1:170 E 78TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0408
Practice Address - Country:US
Practice Address - Phone:516-313-8642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244392207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty