Healthcare Provider Details

I. General information

NPI: 1720257223
Provider Name (Legal Business Name): BABAK MARDEKHEH RAFIEI RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149-55 MYRTLE AVENUE
BROOKLYN NM
11206
US

IV. Provider business mailing address

22 CHAPEL ST
BROOKLYN NY
11201-1903
US

V. Phone/Fax

Practice location:
  • Phone: 718-574-1928
  • Fax: 718-919-2374
Mailing address:
  • Phone: 718-260-2962
  • Fax: 718-522-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011285
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: