Provider Demographics
NPI:1710062468
Name:NEJATHEIM, MASOOD (MD)
Entity Type:Individual
Prefix:
First Name:MASOOD
Middle Name:
Last Name:NEJATHEIM
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 1:265 EAST MERRICK RD
Mailing Address - Street 2:#103
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580
Mailing Address - Country:US
Mailing Address - Phone:516-825-1667
Mailing Address - Fax:516-825-4006
Practice Address - Street 1:265 EAST MERRICK RD
Practice Address - Street 2:#103
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580
Practice Address - Country:US
Practice Address - Phone:516-825-1667
Practice Address - Fax:516-825-4006
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144875-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY90B071Medicare ID - Type Unspecified
B13914Medicare UPIN