Provider Demographics
NPI:1518057272
Name:IRANI, DANESH
Entity Type:Individual
Prefix:
First Name:DANESH
Middle Name:
Last Name:IRANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31094
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-1094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 GLENRIDGE RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4523
Practice Address - Country:US
Practice Address - Phone:518-952-8142
Practice Address - Fax:518-952-8109
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0047471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02636299Medicaid
NY02636299Medicaid
NYR54791Medicare UPIN