Provider Demographics
NPI:1104959659
Name:MOMTAHEN, SHAHROKH (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHROKH
Middle Name:
Last Name:MOMTAHEN
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 1:102 GRAYSON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4425
Mailing Address - Country:US
Mailing Address - Phone:718-987-2474
Mailing Address - Fax:
Practice Address - Street 1:60 EXECUTIVE BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4710
Practice Address - Country:US
Practice Address - Phone:631-755-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231479-1291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBM9969114OtherDEA