Healthcare Provider Details

I. General information

NPI: 1699861567
Provider Name (Legal Business Name): AYMAN ROUSHDY FARAG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RALPH PL STE 204
STATEN ISLAND NY
10304-4405
US

IV. Provider business mailing address

80 MARCUS DRIVE
MELVILLE NY
11747
US

V. Phone/Fax

Practice location:
  • Phone: 347-286-0741
  • Fax: 347-286-0741
Mailing address:
  • Phone: 631-391-8366
  • Fax: 631-454-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number235487
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number235487
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: