Provider Demographics
NPI:1558406777
Name:DAWOODI, KOOROSH (MD)
Entity Type:Individual
Prefix:
First Name:KOOROSH
Middle Name:
Last Name:DAWOODI
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 1:21 SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-395-2224
Mailing Address - Fax:516-829-1264
Practice Address - Street 1:21 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-395-2224
Practice Address - Fax:516-829-1264
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2177242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY130022952OtherRAILROAD MEDICARE
NY02100732Medicaid
NY04228OtherGHI MEICARE
NY04228OtherGHI MEICARE
NY02100732Medicaid