Provider Demographics
NPI:1699026385
Name:CORONA MEDICAL PC
Entity Type:Organization
Organization Name:CORONA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AFSHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVAKOLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-605-7233
Mailing Address - Street 1:PO BOX 650067
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-0067
Mailing Address - Country:US
Mailing Address - Phone:917-605-7233
Mailing Address - Fax:718-998-4252
Practice Address - Street 1:10308 ROOSEVELT AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2330
Practice Address - Country:US
Practice Address - Phone:718-898-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty