Provider Demographics
NPI:1376500942
Name:FOROUZAN-GANDASHMIN, IRAJ (MD)
Entity Type:Individual
Prefix:
First Name:IRAJ
Middle Name:
Last Name:FOROUZAN-GANDASHMIN
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:ONE CAPITAL WAY MFM DEPT
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534
Mailing Address - Country:US
Mailing Address - Phone:609-537-7262
Mailing Address - Fax:
Practice Address - Street 1:ONE CAPITAL WAY
Practice Address - Street 2:MFM DEPT
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534
Practice Address - Country:US
Practice Address - Phone:609-537-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05962300207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001106461Medicaid
NJ7545509Medicaid
PA509018Medicare ID - Type Unspecified
NJ7545509Medicaid
PA001106461Medicaid