Provider Demographics
NPI:1154396893
Name:MOIENAFSHARI, MOHAMMAD REZA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD REZA
Middle Name:
Last Name:MOIENAFSHARI
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 1:2700 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2547
Mailing Address - Country:US
Mailing Address - Phone:914-607-5730
Mailing Address - Fax:
Practice Address - Street 1:644 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6088
Practice Address - Country:US
Practice Address - Phone:203-210-2810
Practice Address - Fax:203-210-2811
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302563207R00000X
CT039581207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1154396893Medicaid
CT010039581CT05OtherANTHEM
CT2V5309OtherHEALTHNET
CT7871277OtherAETHNA
CT039581OtherCONNECTICARE
CT4658627OtherCIGNA