Provider Demographics
NPI:1174593685
Name:HAERI, FARHAD (PT DPT)
Entity type:Individual
Prefix:DR
First Name:FARHAD
Middle Name:
Last Name:HAERI
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746
Mailing Address - Country:US
Mailing Address - Phone:631-385-0066
Mailing Address - Fax:631-385-0770
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE #200-12
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-385-0066
Practice Address - Fax:631-385-0770
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0155911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02019134Medicaid
Q16B61Medicare PIN