Provider Demographics
NPI:1548271604
Name:FATHOLLAHI, ROYA (MD)
Entity type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:FATHOLLAHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E 30TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8366
Mailing Address - Country:US
Mailing Address - Phone:212-614-0039
Mailing Address - Fax:212-253-9631
Practice Address - Street 1:38 E 32ND ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5507
Practice Address - Country:US
Practice Address - Phone:212-725-2660
Practice Address - Fax:212-725-3660
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5088N2Medicare PIN
NYI00461Medicare UPIN