Healthcare Provider Details

I. General information

NPI: 1083664767
Provider Name (Legal Business Name): A. KHODADADI RADIOLOGY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2678 GERRITSEN AVE
BROOKLYN NY
11229-5947
US

IV. Provider business mailing address

2678 GERRITSEN AVE
BROOKLYN NY
11229-5947
US

V. Phone/Fax

Practice location:
  • Phone: 718-333-0275
  • Fax: 718-333-0224
Mailing address:
  • Phone: 718-333-0275
  • Fax: 718-333-0224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number113253-1
License Number StateNY

VIII. Authorized Official

Name: DR. AYOOB KHODADADI
Title or Position: PRESIDENT
Credential: M.D.,
Phone: 718-333-0207