Provider Demographics
NPI:1417994138
Name:FILSOUFI, FARZAN (MD)
Entity Type:Individual
Prefix:
First Name:FARZAN
Middle Name:
Last Name:FILSOUFI
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 1:1190 5TH AVE
Mailing Address - Street 2:BOX 1028
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6503
Mailing Address - Country:US
Mailing Address - Phone:212-659-6800
Mailing Address - Fax:212-659-6818
Practice Address - Street 1:1190 5TH AVE
Practice Address - Street 2:BOX 1028
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6503
Practice Address - Country:US
Practice Address - Phone:212-659-6800
Practice Address - Fax:212-659-6818
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002305208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02662664Medicaid
NY92885510Medicare ID - Type Unspecified
NY02662664Medicaid