Healthcare Provider Details

I. General information

NPI: 1548275902
Provider Name (Legal Business Name): SEAN SHAHEEN TEDJARATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE STE 2575
HAWTHORNE NY
10532-2140
US

IV. Provider business mailing address

19 BRADHURST AVE STE 3100N
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-2181
  • Fax:
Mailing address:
  • Phone: 914-493-2181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number252781
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME 89380
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number252781
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: