Provider Demographics
NPI:1033379151
Name:BAGHERI, BAHARAK (MD)
Entity Type:Individual
Prefix:
First Name:BAHARAK
Middle Name:
Last Name:BAGHERI
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 1:35 BROAD ST
Mailing Address - Street 2:APT #8
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-8305
Mailing Address - Country:US
Mailing Address - Phone:218-760-9019
Mailing Address - Fax:
Practice Address - Street 1:5605 W EUGIE AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1273
Practice Address - Country:US
Practice Address - Phone:623-847-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN507592085R0202X
ME0184302085R0202X
AZ450402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPENDINGMedicaid
AZ641184Medicaid