Healthcare Provider Details

I. General information

NPI: 1790806719
Provider Name (Legal Business Name): AZIM ETEMADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E 96TH ST
NEW YORK NY
10128-6217
US

IV. Provider business mailing address

108 E 96TH ST
NEW YORK NY
10128-6217
US

V. Phone/Fax

Practice location:
  • Phone: 212-348-4849
  • Fax:
Mailing address:
  • Phone: 212-348-4849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number123804
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: