Provider Demographics
NPI:1659546901
Name:EGHRARI, MASSOUD (MD)
Entity Type:Individual
Prefix:
First Name:MASSOUD
Middle Name:
Last Name:EGHRARI
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 1:142 LANDING MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1126
Mailing Address - Country:US
Mailing Address - Phone:631-584-5100
Mailing Address - Fax:631-360-2696
Practice Address - Street 1:142 LANDING MEADOW RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1126
Practice Address - Country:US
Practice Address - Phone:631-584-5100
Practice Address - Fax:631-360-2696
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60091780208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY261731Medicare UPIN