Provider Demographics
NPI:1528148475
Name:TAVAKOLI, KAMYAR D (MD,)
Entity type:Individual
Prefix:DR
First Name:KAMYAR
Middle Name:D
Last Name:TAVAKOLI
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:PO BOX 231301
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-0301
Mailing Address - Country:US
Mailing Address - Phone:718-217-5200
Mailing Address - Fax:
Practice Address - Street 1:19115 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1941
Practice Address - Country:US
Practice Address - Phone:718-217-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01089Medicare ID - Type Unspecified
NY59H482Medicare PIN
01089Medicare ID - Type Unspecified