Provider Demographics
NPI:1073889051
Name:ENTEZARI, VAHID (MD MMSC)
Entity Type:Individual
Prefix:
First Name:VAHID
Middle Name:
Last Name:ENTEZARI
Suffix:
Gender:M
Credentials:MD MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W ELM ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-4108
Mailing Address - Country:US
Mailing Address - Phone:610-567-6964
Mailing Address - Fax:
Practice Address - Street 1:501 S 54TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1900
Practice Address - Country:US
Practice Address - Phone:215-748-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461913207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty