Provider Demographics
NPI:1144373929
Name:MAHDAVIAN, JAMAL (MD)
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:MAHDAVIAN
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 1:40 HURLEY AVE SUITE 5
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-338-9488
Mailing Address - Fax:845-338-6774
Practice Address - Street 1:40 HURLEY AVE SUITE 5
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-338-9488
Practice Address - Fax:845-338-6774
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207514-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCJ9902OtherRAILROAD MEDICARE
NY01770869Medicaid
NY01770869Medicaid