Healthcare Provider Details

I. General information

NPI: 1780786517
Provider Name (Legal Business Name): PEDRAM HENDIZADEH D.P.M., F.A.C.F.A.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 NORTHERN BLVD
MANHASSET NY
11030-3502
US

IV. Provider business mailing address

2110 NORTHERN BLVD SUITE 208
MANHASSET NY
11030-3502
US

V. Phone/Fax

Practice location:
  • Phone: 516-869-3300
  • Fax:
Mailing address:
  • Phone: 516-869-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number005950
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: