Healthcare Provider Details

I. General information

NPI: 1285639591
Provider Name (Legal Business Name): JERALD DARVISHZADEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FRANKLIN AVE ANESTHESIA DEPARTMENT
VALLEY STREAM NY
11580-2145
US

IV. Provider business mailing address

66 POWERHOUSE RD 3RD FLOOR
ROSLYN HEIGHTS NY
11577-1324
US

V. Phone/Fax

Practice location:
  • Phone: 516-256-6134
  • Fax:
Mailing address:
  • Phone: 516-626-6366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number229816
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: