Provider Demographics
NPI:1801819180
Name:SHOKRI-TABIBZADEH, FARZAD (MD)
Entity Type:Individual
Prefix:DR
First Name:FARZAD
Middle Name:
Last Name:SHOKRI-TABIBZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FARZAD
Other - Middle Name:
Other - Last Name:SHOKRI-TABIBZADEH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22 SOUTH MARYLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2913
Mailing Address - Country:US
Mailing Address - Phone:516-767-2576
Mailing Address - Fax:516-767-0312
Practice Address - Street 1:22 SOUTH MARYLAND AVENUE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2913
Practice Address - Country:US
Practice Address - Phone:516-767-2576
Practice Address - Fax:516-767-0312
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G08300Medicare UPIN