Healthcare Provider Details

I. General information

NPI: 1104950237
Provider Name (Legal Business Name): SAID MOHEBBAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N GANNON AVE
STATEN ISLAND NY
10314-4374
US

IV. Provider business mailing address

65 MELHORN RD
STATEN ISLAND NY
10314-5512
US

V. Phone/Fax

Practice location:
  • Phone: 718-698-6686
  • Fax: 718-529-5930
Mailing address:
  • Phone: 718-698-6686
  • Fax: 718-529-5930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number114129
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: