Provider Demographics
NPI:1275730087
Name:MUKHTARZAD, ROYA (DO)
Entity Type:Individual
Prefix:DR
First Name:ROYA
Middle Name:
Last Name:MUKHTARZAD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 E 57TH ST
Mailing Address - Street 2:#4E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2909
Mailing Address - Country:US
Mailing Address - Phone:917-406-6377
Mailing Address - Fax:
Practice Address - Street 1:86 EAST 49TH STREET
Practice Address - Street 2:SUITE D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203
Practice Address - Country:US
Practice Address - Phone:718-604-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244767207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02903024Medicaid
NY244767OtherNY LICENSE NUMBER
NY24C111Medicare PIN