Provider Demographics
NPI:1316195274
Name:GHAFGHAZI, SHAHAB (MD)
Entity Type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:GHAFGHAZI
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-4600
Mailing Address - Fax:502-588-4693
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:SUITE 310
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5703
Practice Address - Country:US
Practice Address - Phone:502-588-4600
Practice Address - Fax:502-588-4693
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44594207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program