Provider Demographics
NPI:1386042489
Name:DR GHAZALEH BAHRAMI PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DR GHAZALEH BAHRAMI PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GHAZALEH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHRAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-801-5842
Mailing Address - Street 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:#1126
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:1375 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3382
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty