Provider Demographics
NPI:1205389715
Name:EBRAHIMPOUR, PANTEA (MD)
Entity Type:Individual
Prefix:
First Name:PANTEA
Middle Name:
Last Name:EBRAHIMPOUR
Suffix:
Gender:F
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:103 MILLBURY ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-3205
Practice Address - Country:US
Practice Address - Phone:508-721-4100
Practice Address - Fax:508-721-4124
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA281401207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine