Provider Demographics
NPI:1871563304
Name:KHODADADIAN, PARVIS K (MD)
Entity type:Individual
Prefix:
First Name:PARVIS
Middle Name:K
Last Name:KHODADADIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E SUNRISE HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2598
Mailing Address - Country:US
Mailing Address - Phone:631-225-7200
Mailing Address - Fax:631-225-4565
Practice Address - Street 1:150 E SUNRISE HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2598
Practice Address - Country:US
Practice Address - Phone:631-225-7200
Practice Address - Fax:631-225-4565
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1134992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00206340Medicaid
NY00206340Medicaid
NY712431Medicare ID - Type Unspecified