Healthcare Provider Details

I. General information

NPI: 1912712332
Provider Name (Legal Business Name): ELIYAHU FAKHERI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SUMNER PLACE
BROOKLYN NY
11206
US

IV. Provider business mailing address

623 AVENUE L
BROOKLYN NY
11230-5109
US

V. Phone/Fax

Practice location:
  • Phone: 917-346-1092
  • Fax:
Mailing address:
  • Phone: 917-346-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number033029-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: