Provider Demographics
NPI:1073055257
Name:MAMAD BAGHERI MD PA
Entity Type:Organization
Organization Name:MAMAD BAGHERI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGHERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-500-7286
Mailing Address - Street 1:4327 BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-2303
Mailing Address - Country:US
Mailing Address - Phone:951-500-7286
Mailing Address - Fax:
Practice Address - Street 1:4327 BARNETT RD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-2303
Practice Address - Country:US
Practice Address - Phone:951-500-7286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-05
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty