Provider Demographics
NPI:1447215678
Name:BEHNAM, AMIR BABAK (MD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:BABAK
Last Name:BEHNAM
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:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2610 KEISER BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3333
Practice Address - Country:US
Practice Address - Phone:484-628-9127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA077822002086S0105X, 2086S0122X
PAMD4356322086S0105X, 2086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102209241Medicaid
PA102209241Medicaid
096917Medicare ID - Type Unspecified