Healthcare Provider Details

I. General information

NPI: 1659311496
Provider Name (Legal Business Name): AZITA SARA KHORSANDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 4TH AVE
NEW YORK NY
10003-4901
US

IV. Provider business mailing address

10 EXCHANGE PL 14 FLOOR - WSBS
JERSEY CITY NJ
07302-3918
US

V. Phone/Fax

Practice location:
  • Phone: 212-473-2300
  • Fax: 212-473-4780
Mailing address:
  • Phone: 201-830-3200
  • Fax: 201-200-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number194066
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: