MEDICARE: MR. KHOSROW G MOGHADDAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	037245	NY

General Provider Information

NPI Number	:	1295903474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KHOSROW G MOGHADDAM

Provider Business Mailing Address
First Line	:	22 FOXWOOD RD
Second Line	:
City	:	KINGS POINT
State	:	NY
Zip	:	11024-1202
Country	:	US
Telephone Number	:	516-829-2976
Fax Number	:

Provider Business Practice Location Address
First Line	:	20419 HILLSIDE AVE
Second Line	:
City	:	HOLLIS
State	:	NY
Zip	:	11423-2213
Country	:	US
Telephone Number	:	718-465-2121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2008
Last Update Date	:	02/11/2008

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