Healthcare Provider Details

I. General information

NPI: 1649472317
Provider Name (Legal Business Name): MOHSEN DAVOUDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CPMP, HSC L5, RM 048, 100 NICOLLS ROAD
STONY BROOK NY
11794-8552
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 917-414-9517
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA86885
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1026247
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number1026247
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA86885
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA86885
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number1026247
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: