Provider Demographics
NPI:1770552465
Name:ALIZADEH, KAVEH
Entity type:Individual
Prefix:
First Name:KAVEH
Middle Name:
Last Name:ALIZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E 87TH ST
Mailing Address - Street 2:#P4B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1116
Mailing Address - Country:US
Mailing Address - Phone:929-800-1887
Mailing Address - Fax:
Practice Address - Street 1:120 E 87TH ST
Practice Address - Street 2:#P4B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1116
Practice Address - Country:US
Practice Address - Phone:929-800-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02620235Medicaid
NY02620235Medicaid
NY42L891Medicare ID - Type Unspecified