Provider Demographics
NPI:1467560201
Name:BAGHERI, MAMAD MIRZA (MD)
Entity Type:Individual
Prefix:
First Name:MAMAD
Middle Name:MIRZA
Last Name:BAGHERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMMED
Other - Middle Name:MIRZA
Other - Last Name:BAGHERI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4327 BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-2303
Mailing Address - Country:US
Mailing Address - Phone:940-687-3376
Mailing Address - Fax:940-687-3377
Practice Address - Street 1:4327 BARNETT RD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-2303
Practice Address - Country:US
Practice Address - Phone:940-687-3376
Practice Address - Fax:940-687-3377
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1792207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
006759477OtherAETNA
ND154H3BAOtherBC BS MINNESOTA
MN686405000OtherDEPT OF HUMAN SERVICES
CADF1942OtherRAILROAD MEDICARE GROUP
CAP00346003OtherRAILROAD MEDICARE
ND27619OtherBLUE CROSS BLUE SHIELD
CAA82406OtherCA STATE MED LICENSE
NDP00390315OtherRAILROAD MEDICARE
CAZZZ30167ZOtherMEDICARE NHIC
ND14037Medicaid
NDP00390315OtherRAILROAD MEDICARE
CADF1942OtherRAILROAD MEDICARE GROUP
CA00A824061Medicare PIN
CAA82406OtherCA STATE MED LICENSE
CA00A824062Medicare PIN