Healthcare Provider Details

I. General information

NPI: 1083238463
Provider Name (Legal Business Name): NAKISA HEKMAT-JOO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date: 01/18/2022
Reactivation Date: 02/10/2022

III. Provider practice location address

475 SEAVIEW AVENUE 475 SEAVIEW AVENUE
STATEN ISLAND NY
10305
US

IV. Provider business mailing address

28 ANNDALE DR.
TORONTO ONTARIO
M2N 2X1
CA

V. Phone/Fax

Practice location:
  • Phone: 718-226-8855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: