Provider Demographics
NPI:1467423186
Name:MOOSAZADEH, KIOOMARS (MD)
Entity Type:Individual
Prefix:
First Name:KIOOMARS
Middle Name:
Last Name:MOOSAZADEH
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 1:2318 31ST ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2892
Mailing Address - Country:US
Mailing Address - Phone:718-777-1885
Mailing Address - Fax:718-777-9613
Practice Address - Street 1:2318 31ST ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2892
Practice Address - Country:US
Practice Address - Phone:718-777-1885
Practice Address - Fax:718-777-9613
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2383592081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY238359OtherLICENSE
NY238359OtherLICENSE