Provider Demographics
NPI:1558501668
Name:ANOOSH, FARHAD (MD)
Entity Type:Individual
Prefix:
First Name:FARHAD
Middle Name:
Last Name:ANOOSH
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 1:55 MEDFORD AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1229
Mailing Address - Country:US
Mailing Address - Phone:631-687-5400
Mailing Address - Fax:
Practice Address - Street 1:55 MEDFORD AVE
Practice Address - Street 2:SUITE D
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1229
Practice Address - Country:US
Practice Address - Phone:631-687-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD436039208600000X
CT046599208600000X
CAA 113637208600000X
NY256590208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery