Provider Demographics
NPI:1770931982
Name:ESMAEILZADEH, MOHAMMAD (PA)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:ESMAEILZADEH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OLD WESTBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2215
Mailing Address - Country:US
Mailing Address - Phone:516-467-6930
Mailing Address - Fax:
Practice Address - Street 1:1700 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7955
Practice Address - Country:US
Practice Address - Phone:631-665-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019622-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical