Provider Demographics
NPI:1649472317
Name:DAVOUDI, MOHSEN (MD)
Entity type:Individual
Prefix:
First Name:MOHSEN
Middle Name:
Last Name:DAVOUDI
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:CPMP, HSC L5, RM 048, 100 NICOLLS ROAD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8552
Mailing Address - Country:US
Mailing Address - Phone:917-414-9517
Mailing Address - Fax:
Practice Address - Street 1:CPMP, HSC L5, RM 048, 100 NICOLLS ROAD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8552
Practice Address - Country:US
Practice Address - Phone:917-414-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86885207RC0200X, 207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH83221Medicare UPIN