Healthcare Provider Details

I. General information

NPI: 1063496768
Provider Name (Legal Business Name): HADI KOOHSARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 UNION ST
SCHENECTADY NY
12305-1504
US

IV. Provider business mailing address

701 UNION ST
SCHENECTADY NY
12305-1504
US

V. Phone/Fax

Practice location:
  • Phone: 518-374-1610
  • Fax: 518-374-3512
Mailing address:
  • Phone: 518-374-1610
  • Fax: 518-374-3512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2086081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: