Provider Demographics
NPI:1346332301
Name:TEHRANI, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:TEHRANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KAYVON
Other - Middle Name:
Other - Last Name:TEHRANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:560 NORTHERN BLVD
Mailing Address - Street 2:GREAT NECK
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5100
Mailing Address - Country:US
Mailing Address - Phone:516-498-9790
Mailing Address - Fax:516-498-9796
Practice Address - Street 1:560 NORTHERN BLVD
Practice Address - Street 2:GREAT NECK
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5100
Practice Address - Country:US
Practice Address - Phone:516-498-9790
Practice Address - Fax:516-498-9796
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214939174400000X, 2086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No174400000XOther Service ProvidersSpecialist
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY214939OtherLISENCE NUMBER
NYP2995192OtherOXFORD PROVIDER ID
NYN84003OtherACS HEAT NET PROVIDER ID
NY02463385Medicaid
NYH99994Medicare UPIN
NY1467F1Medicare PIN