Provider Demographics
NPI:1134174782
Name:GHOLOMHASSANI, AFSHIN (MD)
Entity type:Individual
Prefix:
First Name:AFSHIN
Middle Name:
Last Name:GHOLOMHASSANI
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 1:3778 ILLONA LN
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5973
Mailing Address - Country:US
Mailing Address - Phone:718-634-7000
Mailing Address - Fax:718-634-7600
Practice Address - Street 1:230 BEACH 102ND ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2871
Practice Address - Country:US
Practice Address - Phone:718-634-7000
Practice Address - Fax:718-634-7600
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218325-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02045687Medicaid
NY02045687Medicaid
NYG99970Medicare UPIN