Provider Demographics
NPI:1295903474
Name:MOGHADDAM, KHOSROW G
Entity type:Individual
Prefix:MR
First Name:KHOSROW
Middle Name:G
Last Name:MOGHADDAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 FOXWOOD RD
Mailing Address - Street 2:
Mailing Address - City:KINGS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1202
Mailing Address - Country:US
Mailing Address - Phone:516-829-2976
Mailing Address - Fax:
Practice Address - Street 1:20419 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2213
Practice Address - Country:US
Practice Address - Phone:718-465-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist