Healthcare Provider Details

I. General information

NPI: 1063161412
Provider Name (Legal Business Name): MIRHOJJAT KHORASANIZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 MADISON AVE FL 8
NEW YORK NY
10029-6508
US

IV. Provider business mailing address

PO BOX 1136
NEW YORK NY
10029-0312
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: