Provider Demographics
NPI:1215462122
Name:KHODAK, MEGHEDY SHANAZARIAN (MD)
Entity type:Individual
Prefix:DR
First Name:MEGHEDY
Middle Name:SHANAZARIAN
Last Name:KHODAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MEGHEDY
Other - Middle Name:
Other - Last Name:SHANAZARIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:809 EAST RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-0310
Mailing Address - Fax:585-266-9207
Practice Address - Street 1:809 EAST RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-266-0310
Practice Address - Fax:585-266-9207
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NY305460208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty