Provider Demographics
NPI:1316994718
Name:KHODABAKHSH, SAEID (MD)
Entity type:Individual
Prefix:
First Name:SAEID
Middle Name:
Last Name:KHODABAKHSH
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 1:2554 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-4904
Mailing Address - Country:US
Mailing Address - Phone:718-240-8600
Mailing Address - Fax:718-240-8607
Practice Address - Street 1:2554 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-4904
Practice Address - Country:US
Practice Address - Phone:718-240-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185991208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04L541Medicare ID - Type Unspecified
F70796Medicare UPIN