Healthcare Provider Details

I. General information

NPI: 1962767632
Provider Name (Legal Business Name): FATEMEH MALEKPOUR GHORBANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SEAVIEW AVE STE 302
STATEN ISLAND NY
10305-3400
US

IV. Provider business mailing address

501 SEAVIEW AVE STE 302
STATEN ISLAND NY
10305-3400
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6800
  • Fax:
Mailing address:
  • Phone: 718-226-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR0611
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number298364
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: