Provider Demographics
NPI:1194752428
Name:KAMKHEHJI, AZAR
Entity type:Individual
Prefix:
First Name:AZAR
Middle Name:
Last Name:KAMKHEHJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 AVENUE S
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3621
Mailing Address - Country:US
Mailing Address - Phone:718-332-8428
Mailing Address - Fax:718-332-6435
Practice Address - Street 1:510 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-2886
Practice Address - Country:US
Practice Address - Phone:718-282-3600
Practice Address - Fax:718-282-7066
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02581771Medicaid
NY02581771Medicaid