Provider Demographics
NPI:1790744258
Name:SEDAGHATPOUR, NASSER (MD)
Entity Type:Individual
Prefix:
First Name:NASSER
Middle Name:
Last Name:SEDAGHATPOUR
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:PO BOX 5450
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5450
Mailing Address - Country:US
Mailing Address - Phone:718-780-3139
Mailing Address - Fax:718-780-3774
Practice Address - Street 1:506 6 STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-780-3139
Practice Address - Fax:718-780-3774
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1159862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00214668Medicaid
B17557Medicare UPIN
NY653312Medicare PIN