Healthcare Provider Details

I. General information

NPI: 1396972725
Provider Name (Legal Business Name): FARHAD KADKHODAEI ELYADERANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 BRONX BLVD FRNT 1
BRONX NY
10466-2669
US

IV. Provider business mailing address

4234 BRONX BLVD FRNT 1
BRONX NY
10466-2669
US

V. Phone/Fax

Practice location:
  • Phone: 718-515-4347
  • Fax: 718-653-8641
Mailing address:
  • Phone: 718-515-4347
  • Fax: 718-653-8641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number274613
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: