Provider Demographics
NPI:1588751333
Name:ROUSTA, MEHDI (MD)
Entity type:Individual
Prefix:
First Name:MEHDI
Middle Name:
Last Name:ROUSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WEST 33RD STREET
Mailing Address - Street 2:PBS 12TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:212-356-4474
Mailing Address - Fax:212-356-4608
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:SURGERY
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3611
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125645208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00249261Medicaid
B13221Medicare UPIN
NC00249261Medicaid