Provider Demographics
NPI:1215916721
Name:HORMOZI, SHAHRAM (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:HORMOZI
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 1:515 ROUTE 111
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4339
Mailing Address - Country:US
Mailing Address - Phone:631-224-1819
Mailing Address - Fax:631-224-1812
Practice Address - Street 1:515 ROUTE 111
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788
Practice Address - Country:US
Practice Address - Phone:631-224-1819
Practice Address - Fax:631-224-1812
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201817207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA71817OtherMDNY
NY2197789OtherGHI
NY608P41OtherEMPIRE BCBS
NY163571OtherVYTRA
NY3777960OtherAETNA/US HEALTHCARE
NYP2531781OtherOXFORD
NY02192487Medicaid
NY58313POtherHIP
NY02192487Medicaid
NYAA71817OtherMDNY