Provider Demographics
NPI:1831254861
Name:MOGTADERI, FAZLOLLAH FRAYDOON (MD)
Entity type:Individual
Prefix:DR
First Name:FAZLOLLAH
Middle Name:FRAYDOON
Last Name:MOGTADERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:520 E 72 STREET
Mailing Address - Street 2:SUTIE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4852
Mailing Address - Country:US
Mailing Address - Phone:212-876-2322
Mailing Address - Fax:212-860-2425
Practice Address - Street 1:520 E 72 STREET
Practice Address - Street 2:SUTIE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4852
Practice Address - Country:US
Practice Address - Phone:212-876-2322
Practice Address - Fax:212-860-2425
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1176921208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
N61821OtherHEALTHNET
0095588OtherGHI
898073OtherEMPIRE BLUE SHIELD
004928OtherPHS
NS1914OtherOXFORD
898071Medicare ID - Type Unspecified
898073OtherEMPIRE BLUE SHIELD