Healthcare Provider Details

I. General information

NPI: 1457895278
Provider Name (Legal Business Name): MOHAMMAD DJAFARI MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15-17 KENNEDY PARKWAY
CORTLAND NY
13045
US

IV. Provider business mailing address

15-17 KENNEDY PARKWAY
CORTLAND NY
13045
US

V. Phone/Fax

Practice location:
  • Phone: 607-753-3051
  • Fax: 607-753-7735
Mailing address:
  • Phone: 607-753-3051
  • Fax: 607-753-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number211106
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007997
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number382461
License Number StateNY

VIII. Authorized Official

Name: DR. MOHAMMAD DJAFARI
Title or Position: OWNER
Credential: MD
Phone: 607-753-3051