Provider Demographics
NPI:1164528006
Name:GHAZVINIAN, SASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SASAN
Middle Name:
Last Name:GHAZVINIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SASAN
Other - Middle Name:
Other - Last Name:GHAZVINIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:42 NEBO ST
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2215
Mailing Address - Country:US
Mailing Address - Phone:617-323-7700
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:617-323-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA36271OtherLICENSE