Provider Demographics
NPI:1447246756
Name:FARAHMANDPOUR, BEHROUZ (DO)
Entity type:Individual
Prefix:
First Name:BEHROUZ
Middle Name:
Last Name:FARAHMANDPOUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 COMMACK RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5522
Mailing Address - Country:US
Mailing Address - Phone:631-940-0409
Mailing Address - Fax:631-940-1834
Practice Address - Street 1:375 COMMACK RD UNIT A
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5522
Practice Address - Country:US
Practice Address - Phone:631-940-0409
Practice Address - Fax:631-940-1834
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233446-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI36864Medicare UPIN
NY3181P05882Medicare PIN
NY07239Medicare ID - Type UnspecifiedGHI