Provider Demographics
NPI:1659140747
Name:BRIAN GHEZELAIAGH, MD, PC
Entity Type:Organization
Organization Name:BRIAN GHEZELAIAGH, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHEZELAIAGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-210-6305
Mailing Address - Street 1:2500 NESCONSET HWY BLDG 17C
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2563
Mailing Address - Country:US
Mailing Address - Phone:631-210-6305
Mailing Address - Fax:631-292-7376
Practice Address - Street 1:2500 NESCONSET HWY BLDG 17C
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2563
Practice Address - Country:US
Practice Address - Phone:631-210-6305
Practice Address - Fax:631-292-7376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty