Provider Demographics
NPI:1659449338
Name:GOLESTANEH, NASSER (MD)
Entity Type:Individual
Prefix:
First Name:NASSER
Middle Name:
Last Name:GOLESTANEH
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 1:5 ROSCOE CT
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548
Mailing Address - Country:US
Mailing Address - Phone:516-484-5874
Mailing Address - Fax:
Practice Address - Street 1:1199 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:718-859-7446
Practice Address - Fax:718-859-3395
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118735208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00221696Medicaid
B14919Medicare UPIN
NY00221696Medicaid