Healthcare Provider Details

I. General information

NPI: 1518596345
Provider Name (Legal Business Name): SHAYAN FAKURNEJAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BAINBRIDGE AVE FL 3
BRONX NY
10467-2404
US

IV. Provider business mailing address

3400 BAINBRIDGE AVE FL 3
BRONX NY
10467-2404
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-8425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number344368
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: