Healthcare Provider Details

I. General information

NPI: 1255350468
Provider Name (Legal Business Name): MASEIH MOGHADDASSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MINEOLA BLVD
MINEOLA NY
11501
US

IV. Provider business mailing address

134 MINEOLA BLVD
MINEOLA NY
11501
US

V. Phone/Fax

Practice location:
  • Phone: 516-294-9363
  • Fax: 516-294-9228
Mailing address:
  • Phone: 516-294-9363
  • Fax: 516-294-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number193774
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: