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General NPI Number Information
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NPI Number | 1659140747
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Entity Type | Organization
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Legal Business Name | BRIAN GHEZELAIAGH, MD, PC
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Dates
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Enumeration Date | 12/29/2023
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Last Update Date | 12/29/2023
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Provider Practice Location Address
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Address Line | 2500 NESCONSET HWY BLDG 17C
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City | STONY BROOK
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State | NY
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Zip | 11790-2563
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Country | US
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Telephone | 631-210-6305
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Fax | 631-292-7376
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Provider Business Mailing Address
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Address Line | 2500 NESCONSET HWY BLDG 17C
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City | STONY BROOK
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State | NY
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Zip | 11790-2563
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Country | US
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Telephone | 631-210-6305
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Fax | 631-292-7376
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRIAN GHEZELAIAGH
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Credential | MD
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Telephone | 631-210-6305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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