Provider Demographics
NPI:1578813838
Name:BETHPAGE MEDICAL WELLNESS PC
Entity Type:Organization
Organization Name:BETHPAGE MEDICAL WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHOURZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-597-4433
Mailing Address - Street 1:4250 HEMSTEAD TURNPIKE
Mailing Address - Street 2:SUITE 19
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5707
Mailing Address - Country:US
Mailing Address - Phone:516-597-4433
Mailing Address - Fax:
Practice Address - Street 1:4250 HEMPSTEAD TPKE
Practice Address - Street 2:SUITE 19
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5711
Practice Address - Country:US
Practice Address - Phone:516-597-4433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02227989Medicaid