Healthcare Provider Details

I. General information

NPI: 1821244724
Provider Name (Legal Business Name): ARDAVAN AKHAVAN M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST BOX 94, RM F931
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

525 E 68TH ST BOX 94, RM F931
NEW YORK NY
10065-4870
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-5361
  • Fax: 212-746-8149
Mailing address:
  • Phone: 212-746-5361
  • Fax: 212-746-8149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberMD60282107
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberD0077591
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number254073
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: