Healthcare Provider Details

I. General information

NPI: 1316994718
Provider Name (Legal Business Name): SAEID KHODABAKHSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 10/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2554 LINDEN BLVD
BROOKLYN NY
11208-4904
US

IV. Provider business mailing address

2554 LINDEN BLVD
BROOKLYN NY
11208-4904
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-8600
  • Fax:
Mailing address:
  • Phone: 718-240-8600
  • Fax: 718-240-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number185991
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: