Provider Demographics
NPI:1649502287
Name:JAVDAN, OMID ZACK (DO)
Entity type:Individual
Prefix:DR
First Name:OMID
Middle Name:ZACK
Last Name:JAVDAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 COMMUNITY DR STE 206
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3821
Mailing Address - Country:US
Mailing Address - Phone:516-403-9104
Mailing Address - Fax:516-217-1852
Practice Address - Street 1:800 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3822
Practice Address - Country:US
Practice Address - Phone:516-403-9104
Practice Address - Fax:516-217-1852
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263217207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04504385Medicaid
NYA400145350Medicare PIN
NY04504385Medicaid