Provider Demographics
NPI:1275975070
Name:POURREZAEI, KIMIA (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMIA
Middle Name:
Last Name:POURREZAEI
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 1:119 AINSLIE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-3539
Mailing Address - Country:US
Mailing Address - Phone:215-479-8282
Mailing Address - Fax:
Practice Address - Street 1:111 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075
Practice Address - Country:US
Practice Address - Phone:212-434-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2833662084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry