Provider Demographics
NPI:1447220017
Name:HAERI-GHARAVI, GHOL B (MD)
Entity Type:Individual
Prefix:
First Name:GHOL
Middle Name:B
Last Name:HAERI-GHARAVI
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 22
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302
Mailing Address - Country:US
Mailing Address - Phone:661-335-7755
Mailing Address - Fax:661-335-7766
Practice Address - Street 1:4545 STOCKDALE HWY
Practice Address - Street 2:#A
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309
Practice Address - Country:US
Practice Address - Phone:661-335-7755
Practice Address - Fax:661-335-7766
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38702207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A387020Medicaid
CA00A387020Medicare ID - Type Unspecified
C03983Medicare UPIN