Healthcare Provider Details

I. General information

NPI: 1003495045
Provider Name (Legal Business Name): PEIMAN GHATAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 CENTRAL AVE UNIT B
CEDARHURST NY
11516-1920
US

IV. Provider business mailing address

409 CENTRAL AVE UNIT B
CEDARHURST NY
11516-1920
US

V. Phone/Fax

Practice location:
  • Phone: 516-453-4553
  • Fax: 516-879-5081
Mailing address:
  • Phone: 516-453-4553
  • Fax: 516-879-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number026513
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number026513
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: