Basic Information
| Provider Information | |||||||||
| NPI: | 1154396893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOIENAFSHARI | ||||||||
| FirstName: | MOHAMMAD REZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146075730 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 644 W PUTNAM AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068306088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032102810 | ||||||||
| FaxNumber: | 2032102811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 01/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 302563 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 039581 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1154396893 | 05 | CT | MEDICAID |