Provider Demographics
NPI:1184689515
Name:MOFTAKHAR, ROHAM (MD)
Entity Type:Individual
Prefix:
First Name:ROHAM
Middle Name:
Last Name:MOFTAKHAR
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 310
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6849
Practice Address - Country:US
Practice Address - Phone:803-434-8323
Practice Address - Fax:803-434-8326
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-129390207T00000X
SC37893207T00000X
WI47499207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC378932Medicaid
SC378932Medicaid