Provider Demographics
NPI:1336319870
Name:MANUCHEHR SASANNEJAD MD
Entity Type:Organization
Organization Name:MANUCHEHR SASANNEJAD MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUCHEHR
Authorized Official - Middle Name:
Authorized Official - Last Name:SASANNEJAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-343-1856
Mailing Address - Street 1:510 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2632
Mailing Address - Country:US
Mailing Address - Phone:845-343-1856
Mailing Address - Fax:845-343-0611
Practice Address - Street 1:510 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2632
Practice Address - Country:US
Practice Address - Phone:845-343-1856
Practice Address - Fax:845-343-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121795207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00386085Medicaid
NY45D413Medicare PIN