Provider Demographics
NPI:1922396472
Name:MANHATTAN GASTROENTEROLOGY P.C.
Entity Type:Organization
Organization Name:MANHATTAN GASTROENTEROLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODADADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-313-8642
Mailing Address - Street 1:121 W 27TH ST STE 504
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6207
Mailing Address - Country:US
Mailing Address - Phone:212-427-8761
Mailing Address - Fax:212-427-8762
Practice Address - Street 1:55 W 17TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-5513
Practice Address - Country:US
Practice Address - Phone:212-427-8761
Practice Address - Fax:212-427-8762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207N00000X, 207R00000X, 207RG0100X, 207VG0400X, 213E00000X
NY244392207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100252116OtherMEDICARE PTAN