Healthcare Provider Details

I. General information

NPI: 1376598805
Provider Name (Legal Business Name): ALI AHMADIZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 OLD COUNTRY RD
PLAINVIEW NY
11803-4942
US

IV. Provider business mailing address

875 OLD COUNTRY RD
PLAINVIEW NY
11803-4942
US

V. Phone/Fax

Practice location:
  • Phone: 516-931-5552
  • Fax:
Mailing address:
  • Phone: 516-931-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number254098
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number254098
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03239012
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: