Healthcare Provider Details

I. General information

NPI: 1306106851
Provider Name (Legal Business Name): IMAN KHODARAHMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IMAN KHODARAHMI QAHNAVIEH MD

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 1ST AVE
NEW YORK NY
10016
US

IV. Provider business mailing address

660 1ST AVE FL 3
NEW YORK NY
10016-3295
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5230
  • Fax: 646-754-9560
Mailing address:
  • Phone: 212-263-9531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number294795
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: