Provider Demographics
NPI:1306145057
Name:DAVOUDZADEH, REUBIN POOYA (MD)
Entity type:Individual
Prefix:DR
First Name:REUBIN
Middle Name:POOYA
Last Name:DAVOUDZADEH
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 1:27 GAETANO LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2343
Mailing Address - Country:US
Mailing Address - Phone:516-526-0127
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY267056-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program