Healthcare Provider Details

I. General information

NPI: 1447246756
Provider Name (Legal Business Name): BEHROUZ FARAHMANDPOUR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 COMMACK RD UNIT A
DEER PARK NY
11729-5522
US

IV. Provider business mailing address

375 COMMACK RD UNIT A
DEER PARK NY
11729-5522
US

V. Phone/Fax

Practice location:
  • Phone: 631-940-0409
  • Fax: 631-940-1834
Mailing address:
  • Phone: 631-940-0409
  • Fax: 631-940-1834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number233446-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: