NPIMap

Individual provider Active NPI

Mohammad Amin Khoshnevisan, DMD

  • Oral and Maxillofacial Surgery (Dentist)
  • New York, NY
National Provider Identifier
1114308855
Registry record updated Aug 1, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
062474 Issued in NY
Practice address
630 W 168TH St RM 250
New York, NY 10032-3725
Phone
(212) 342-0424
Fax
(212) 305-9017
NPI assigned
Jun 17, 2015
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Aug 1, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X 30.026201 OH
Dentist 122300000X DS042004 PA
Oral and Maxillofacial Surgery (Dentist) 1223S0112X 018001949 IL
Oral and Maxillofacial Surgery (Dentist) 1223S0112X 062474 NY Primary

Addresses

Primary practice location

630 W 168TH St RM 250
New York, NY 10032-3725

Mailing address

130 Elfreths Aly
Philadelphia, PA 19106-2006

Other practice location 1

1732 S Broad St
Philadelphia, PA 19145-2330
Phone (301) 801-3998

Other practice location 2

6218 Glenway Ave
Cincinnati, OH 45211-6314
Phone (513) 245-8460

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20230131002348 NY Practitioner - Oral Surgery 7719284496 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Oral Surgery
Education
Western University of Health Sciences College of Dental Med, 2015
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

622 W 168TH St
New York, NY 10032-3720
Phone (212) 305-9876

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
100 of 100Reported as apm
Quality
85.32
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
30.026201OHMDDentist
DS042004PAMDDentist
018001949ILMDOral and Maxillofacial Surgery (Dentist)
062474NYMDPediatric Pharmacist

Practice roles

OrganizationSpecialtyStatusNew patients
Trustees of Columbia University in the City of New York Single Specialty Current Accepting new patients
Trustees of Columbia University in the City of New York CurrentSince Sep 14, 2022 Accepting new patients
Trustees of Columbia University in the City of New York Oral and Maxillofacial Surgery CurrentSince Aug 7, 2022 Accepting new patients
Trustees of Columbia University in the City of New York CurrentSince Sep 14, 2022 Accepting new patients
The New York and Presbyterian Hospital Past Accepting new patients
Kireru Dental Associates Inc Single Specialty Past Accepting new patients
Trustees of Columbia University in the Department of Otolaryngology Single Specialty Past Accepting new patients

Locations

630 W 168th St
New York, NY 10032
Phone (212) 305-1948

161 Fort Washington Ave
New York, NY 10032
Phone (212) 305-8559

622 W 168th St
New York, NY 10032
Phone (212) 305-4931

630 W 168th St
Rm 250
New York, NY 10032
Phone (212) 305-7626

630 W 168th St
#7250
New York, NY 10032

Networks

  • Healthfirst Medicare Network H9678
  • Healthfirst Medicare Network H3359
  • Healthfirst Medicare Network H5989
  • Healthfirst Medicare Network H1722

Interoperability endpoints

  • Direct secure messaging: mok7021@direct.nyp.org
  • FHIR API: https://epicproxy-pub.et1089.epichosted.com/FHIRProxy/api/FHIR/R4/
  • FHIR API: https://epicproxy-pub.et1089.epichosted.com/FHIRProxy/api/FHIR/DSTU2/

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1434499200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1659312000000",
    "number": "1114308855",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "130 ELFRETHS ALY",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191062006"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "630 W 168TH ST RM 250",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100323725",
            "telephone_number": "212-342-0424",
            "fax_number": "212-305-9017"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1732 S Broad St",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191452330",
            "country_code": "US",
            "telephone_number": "301-801-3998",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "6218 Glenway Ave",
            "address_purpose": "LOCATION",
            "city": "Cincinnati",
            "state": "OH",
            "postal_code": "452116314",
            "country_code": "US",
            "telephone_number": "513-245-8460",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KHOSHNEVISAN",
        "first_name": "MOHAMMAD AMIN",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2015-06-17",
        "last_updated": "2022-08-01",
        "certification_date": "2022-08-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "OH",
            "license": "30.026201",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "PA",
            "license": "DS042004",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "IL",
            "license": "018001949",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NY",
            "license": "062474",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in New York, NY

Sources for this page

Verify at the official NPI Registry.