Healthcare Provider Details

I. General information

NPI: 1699026385
Provider Name (Legal Business Name): CORONA MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 10/30/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40-11 WARREN ST 2ND FLOOR
ELMHURST NY
11373-1700
US

IV. Provider business mailing address

PO BOX 650067
FRESH MEADOWS NY
11365-0067
US

V. Phone/Fax

Practice location:
  • Phone: 718-426-8100
  • Fax: 718-396-0407
Mailing address:
  • Phone: 917-605-7233
  • Fax: 718-998-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AFSHIN TAVAKOLY
Title or Position: OFFICER/PHYSICIAN
Credential: M.D.
Phone: 917-605-7233