Provider Demographics
NPI:1720241714
Name:KOHANSIEH, MEHRZAD (DC)
Entity Type:Individual
Prefix:
First Name:MEHRZAD
Middle Name:
Last Name:KOHANSIEH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6317 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3641
Mailing Address - Country:US
Mailing Address - Phone:718-335-7700
Mailing Address - Fax:718-335-2254
Practice Address - Street 1:6317 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3641
Practice Address - Country:US
Practice Address - Phone:718-335-7700
Practice Address - Fax:718-335-2254
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU69562Medicare UPIN