Provider Demographics
NPI:1841694353
Name:PARK MEDICAL & DIAGNOSTIC, P.C.
Entity type:Organization
Organization Name:PARK MEDICAL & DIAGNOSTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEHROUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAHMANDPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-271-9017
Mailing Address - Street 1:752 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3900
Mailing Address - Country:US
Mailing Address - Phone:631-271-9017
Mailing Address - Fax:631-385-1272
Practice Address - Street 1:752 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3900
Practice Address - Country:US
Practice Address - Phone:631-271-9017
Practice Address - Fax:631-385-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty