Provider Demographics
NPI:1336154889
Name:MOHASSEL, PARVIZ R (MD)
Entity Type:Individual
Prefix:
First Name:PARVIZ
Middle Name:R
Last Name:MOHASSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PARVIZ
Other - Middle Name:
Other - Last Name:REJAI-MOHASSEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-0194
Mailing Address - Country:US
Mailing Address - Phone:845-856-6671
Mailing Address - Fax:845-858-9903
Practice Address - Street 1:123 PIKE ST
Practice Address - Street 2:SUITE 209
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1824
Practice Address - Country:US
Practice Address - Phone:845-856-6671
Practice Address - Fax:845-858-9903
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01353364Medicaid