Provider Demographics
NPI:1821097080
Name:KHODADADIAN, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KHODADADIAN
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 1:357A CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4701
Mailing Address - Country:US
Mailing Address - Phone:917-853-4691
Mailing Address - Fax:718-573-7856
Practice Address - Street 1:357A CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4701
Practice Address - Country:US
Practice Address - Phone:718-497-1757
Practice Address - Fax:718-573-7856
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202828207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01929111Medicaid
1821097080OtherNPI
NYG89974Medicare UPIN