Provider Demographics
NPI:1174962641
Name:MESBAH MEDICAL PC
Entity type:Organization
Organization Name:MESBAH MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MESBAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-922-2446
Mailing Address - Street 1:10 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2333
Mailing Address - Country:US
Mailing Address - Phone:310-922-2446
Mailing Address - Fax:718-526-7438
Practice Address - Street 1:10 WALNUT DR
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2333
Practice Address - Country:US
Practice Address - Phone:310-922-2446
Practice Address - Fax:718-526-7438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261697261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03375697Medicaid