Provider Demographics
NPI:1780786517
Name:HENDIZADEH, PEDRAM (DPM, FACFAS)
Entity type:Individual
Prefix:
First Name:PEDRAM
Middle Name:
Last Name:HENDIZADEH
Suffix:
Gender:M
Credentials:DPM, FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 NORTHERN BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3502
Mailing Address - Country:US
Mailing Address - Phone:516-869-3300
Mailing Address - Fax:
Practice Address - Street 1:2110 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3502
Practice Address - Country:US
Practice Address - Phone:516-869-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005950213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT480000835Medicare ID - Type Unspecified
CTU82612Medicare UPIN