Provider Demographics
NPI:1114098696
Name:GHAHERI, BOBAK AMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:BOBAK
Middle Name:AMIR
Last Name:GHAHERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BOBBY
Other - Middle Name:AMIR
Other - Last Name:GHAHERI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:SUITE 230
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-488-2600
Practice Address - Fax:503-465-5468
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27404207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8481699Medicaid
OR006246Medicaid
OR006246Medicaid