Provider Demographics
NPI:1235103375
Name:PAHLAVAN, KAMBIZ (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMBIZ
Middle Name:
Last Name:PAHLAVAN
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 1:100 CENTURY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606
Mailing Address - Country:US
Mailing Address - Phone:844-319-0000
Mailing Address - Fax:774-701-0950
Practice Address - Street 1:100 CENTURY DRIVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:844-319-0000
Practice Address - Fax:774-701-0950
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI338322084P0800X
NH36552084P0800X
MA448082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31874200Medicaid
WI31874200Medicaid