Provider Demographics
NPI:1649358094
Name:SASANNEJAD, MANUCHEHR (MD)
Entity type:Individual
Prefix:DR
First Name:MANUCHEHR
Middle Name:
Last Name:SASANNEJAD
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 1:510 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2632
Mailing Address - Country:US
Mailing Address - Phone:845-343-1856
Mailing Address - Fax:845-343-0611
Practice Address - Street 1:510 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2632
Practice Address - Country:US
Practice Address - Phone:845-343-1856
Practice Address - Fax:845-343-0611
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121795207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00386085Medicaid
NY00386085Medicaid
NY45D413Medicare PIN