Provider Demographics
NPI:1336174374
Name:KHODADADIAN, DANIEL K (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:K
Last Name:KHODADADIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:18 FRANKLIN PL
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1229
Mailing Address - Country:US
Mailing Address - Phone:516-829-2020
Mailing Address - Fax:516-829-2026
Practice Address - Street 1:287 NORTHERN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4717
Practice Address - Country:US
Practice Address - Phone:516-829-2020
Practice Address - Fax:516-829-2026
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206436207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02008693Medicaid
42Z362Medicare PIN
NY02008693Medicaid