Healthcare Provider Details

I. General information

NPI: 1104937796
Provider Name (Legal Business Name): FARHANG F EBRAHIMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 RICHMOND AVE SUITE 205
STATEN ISLAND NY
10314
US

IV. Provider business mailing address

97 NEW DORP LN STE A
STATEN ISLAND NY
10306-2364
US

V. Phone/Fax

Practice location:
  • Phone: 718-982-7800
  • Fax: 718-982-7722
Mailing address:
  • Phone: 718-876-6220
  • Fax: 718-876-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number209072
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: