Provider Demographics
NPI:1326645870
Name:GASTRO 2020 PLLC
Entity Type:Organization
Organization Name:GASTRO 2020 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODADADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-659-5229
Mailing Address - Street 1:28 LIGHTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1140
Mailing Address - Country:US
Mailing Address - Phone:516-659-5229
Mailing Address - Fax:
Practice Address - Street 1:9618 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6625
Practice Address - Country:US
Practice Address - Phone:516-487-0360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty