Provider Demographics
NPI:1730355116
Name:BAHARESTANI, SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:BAHARESTANI
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 1:260 E MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-265-8780
Mailing Address - Fax:631-265-8521
Practice Address - Street 1:260 E MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2982
Practice Address - Country:US
Practice Address - Phone:631-265-8780
Practice Address - Fax:631-265-8521
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.098787207W00000X
KY45126207W00000X
NY252341207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000759307OtherBCBS
IN201065620Medicaid
OH000000759307OtherBCBS