Provider Demographics
NPI:1477073864
Name:AINEHSAZAN, EDMOND (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:
Last Name:AINEHSAZAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WOOLEYS LN APT A6
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11129 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5553
Practice Address - Country:US
Practice Address - Phone:718-275-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00357900213ES0103X
NYN007057213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery