Healthcare Provider Details

I. General information

NPI: 1063580744
Provider Name (Legal Business Name): RITA KHANIJOU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 GRANT AVE
BROOKLYN NY
11208-1804
US

IV. Provider business mailing address

31A VALLEY VIEW RD
GREAT NECK NY
11021-3917
US

V. Phone/Fax

Practice location:
  • Phone: 718-827-6565
  • Fax: 718-964-1502
Mailing address:
  • Phone: 718-827-6565
  • Fax: 718-964-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number162506
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: