Provider Demographics
NPI:1740385285
Name:KOROSH, WILLIAM M (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:KOROSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6356
Mailing Address - Country:US
Mailing Address - Phone:718-494-5280
Mailing Address - Fax:
Practice Address - Street 1:1050 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6356
Practice Address - Country:US
Practice Address - Phone:718-494-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011277-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P674444OtherOXFORD
NY01584798Medicaid
NYV4A911Medicare PIN