Provider Demographics
NPI:1326017906
Name:BAGHERI, BOB B (MD)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:B
Last Name:BAGHERI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11565 MOUNTAIN LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1333
Mailing Address - Country:US
Mailing Address - Phone:770-886-5437
Mailing Address - Fax:770-886-9717
Practice Address - Street 1:204 CANTON RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2304
Practice Address - Country:US
Practice Address - Phone:770-886-5437
Practice Address - Fax:770-886-5437
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
GA040865208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00682107DMedicaid