Provider Demographics
NPI:1164443776
Name:GHAMGOSAR, FARROKH (MD)
Entity Type:Individual
Prefix:
First Name:FARROKH
Middle Name:
Last Name:GHAMGOSAR
Suffix:
Gender:M
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:PO BOX 11263
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2263
Mailing Address - Country:US
Mailing Address - Phone:423-778-3274
Mailing Address - Fax:423-778-2255
Practice Address - Street 1:1200 DODSON AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-3214
Practice Address - Country:US
Practice Address - Phone:423-778-2800
Practice Address - Fax:423-778-2806
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF70025Medicare UPIN
TN3816460Medicare ID - Type Unspecified