Provider Demographics
NPI:1659311496
Name:KHORSANDI, AZITA SARA (MD)
Entity Type:Individual
Prefix:
First Name:AZITA
Middle Name:SARA
Last Name:KHORSANDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EXCHANGE PL
Mailing Address - Street 2:14 FLOOR - WSBS
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3918
Mailing Address - Country:US
Mailing Address - Phone:201-830-3200
Mailing Address - Fax:201-200-0838
Practice Address - Street 1:140 4TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4901
Practice Address - Country:US
Practice Address - Phone:212-473-2300
Practice Address - Fax:212-473-4780
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1940662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01906385Medicaid
G86271Medicare UPIN
NY94B071Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID#