Provider Demographics
NPI:1790992030
Name:FRONT STREET MEDICAL PC
Entity Type:Organization
Organization Name:FRONT STREET MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:KHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-565-4370
Mailing Address - Street 1:717 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4534
Mailing Address - Country:US
Mailing Address - Phone:516-565-4370
Mailing Address - Fax:516-565-2644
Practice Address - Street 1:11045 QUEENS BLVD
Practice Address - Street 2:SUITE AA
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5501
Practice Address - Country:US
Practice Address - Phone:718-268-4468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228173208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY228173OtherMED LIC
NY0309J1Medicare ID - Type Unspecified