Provider Demographics
NPI:1952505018
Name:KHODADADIAN, SHAWN (MD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:KHODADADIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:983 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0808
Mailing Address - Country:US
Mailing Address - Phone:212-427-8761
Mailing Address - Fax:212-427-8762
Practice Address - Street 1:983 PARK AVE
Practice Address - Street 2:STE 1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0808
Practice Address - Country:US
Practice Address - Phone:212-427-8761
Practice Address - Fax:212-427-8762
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244392207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology