Provider Demographics
NPI:1639435084
Name:AZIZI-GHANNAD, SADRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SADRA
Middle Name:
Last Name:AZIZI-GHANNAD
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 1:2626 HALPERIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2631
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-286-3991
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-299-7295
Practice Address - Fax:718-299-6797
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283619207R00000X, 207RG0100X
SC87720207RG0100X
IN01085009A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04443367Medicaid