Provider Demographics
NPI:1043377237
Name:MORADI, MARK M (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:MORADI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:265 REVERE ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11577
Mailing Address - Country:US
Mailing Address - Phone:718-380-8080
Mailing Address - Fax:718-380-7649
Practice Address - Street 1:16416 76TH RD
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1255
Practice Address - Country:US
Practice Address - Phone:718-380-8080
Practice Address - Fax:718-380-7649
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY196882207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04521Medicare ID - Type Unspecified
C78931Medicare UPIN