Provider Demographics
NPI:1649996679
Name:GHANNIAIMAN, SAFOORAH
Entity type:Individual
Prefix:
First Name:SAFOORAH
Middle Name:
Last Name:GHANNIAIMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11441 132ND ST
Mailing Address - Street 2:
Mailing Address - City:S OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-2109
Mailing Address - Country:US
Mailing Address - Phone:347-653-5476
Mailing Address - Fax:
Practice Address - Street 1:11441 132ND ST
Practice Address - Street 2:
Practice Address - City:S OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-2109
Practice Address - Country:US
Practice Address - Phone:347-653-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY345172Medicaid