Provider Demographics
NPI:1437142239
Name:GHARAGOZLOO, ALI M (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:M
Last Name:GHARAGOZLOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-434-9307
Mailing Address - Fax:315-434-9317
Practice Address - Street 1:214 KING ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1142
Practice Address - Country:US
Practice Address - Phone:315-393-3600
Practice Address - Fax:315-393-9127
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1985562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01686460Medicaid
NYCC4762Medicare PIN
NYG27042Medicare UPIN
NYDD6316Medicare PIN