Provider Demographics
NPI:1528218773
Name:QANDAH, AZIZ BASEM NICHOLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:AZIZ BASEM NICHOLAS
Middle Name:
Last Name:QANDAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:
Other - Last Name:QANDAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:86 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2389
Mailing Address - Country:US
Mailing Address - Phone:315-792-7629
Mailing Address - Fax:315-792-3617
Practice Address - Street 1:83 GENESEE ST
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2472
Practice Address - Country:US
Practice Address - Phone:315-792-7629
Practice Address - Fax:315-266-1326
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272547207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03786041Medicaid
NY03786041Medicaid