Provider Demographics
NPI:1326457904
Name:GHOLAM, SAMIOLLAH (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMIOLLAH
Middle Name:
Last Name:GHOLAM
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 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:4545 CORDATA PKWY STE 2A
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5682
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA145760207R00000X
WAMD60836207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine