Provider Demographics
NPI:1376657247
Name:HARIRI, ENAYATOLLAH (MD)
Entity Type:Individual
Prefix:
First Name:ENAYATOLLAH
Middle Name:
Last Name:HARIRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-1430
Mailing Address - Country:US
Mailing Address - Phone:718-469-6600
Mailing Address - Fax:718-856-0714
Practice Address - Street 1:2146 BEVERLEY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5406
Practice Address - Country:US
Practice Address - Phone:718-469-6600
Practice Address - Fax:718-856-0714
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00224117Medicaid
NYC08540Medicare UPIN
NY328141Medicare ID - Type Unspecified