Provider Demographics
NPI:1285639591
Name:DARVISHZADEH, JERALD (MD)
Entity type:Individual
Prefix:DR
First Name:JERALD
Middle Name:
Last Name:DARVISHZADEH
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 1:66 POWERHOUSE RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1324
Mailing Address - Country:US
Mailing Address - Phone:516-626-6366
Mailing Address - Fax:
Practice Address - Street 1:900 FRANKLIN AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2145
Practice Address - Country:US
Practice Address - Phone:516-256-6134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229816207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02579679Medicaid
NY02579679Medicaid
NY0421XPMedicare ID - Type Unspecified
NY9L0041Medicare ID - Type Unspecified