Provider Demographics
NPI:1053344481
Name:SERAJI BOZORGZAD, JAHANSHAH (MD)
Entity type:Individual
Prefix:DR
First Name:JAHANSHAH
Middle Name:
Last Name:SERAJI BOZORGZAD
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 1:130 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2740
Mailing Address - Country:US
Mailing Address - Phone:516-596-7600
Mailing Address - Fax:516-596-7601
Practice Address - Street 1:130 MERRICK RD
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2740
Practice Address - Country:US
Practice Address - Phone:516-596-7600
Practice Address - Fax:516-596-7601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218864207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH74238Medicare PIN