Provider Demographics
NPI:1487635405
Name:MOSHTAGHI, FARYAR (DO)
Entity Type:Individual
Prefix:DR
First Name:FARYAR
Middle Name:
Last Name:MOSHTAGHI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N PICKAWAY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1447
Mailing Address - Country:US
Mailing Address - Phone:740-420-8365
Mailing Address - Fax:740-420-8340
Practice Address - Street 1:600 N PICKAWAY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1447
Practice Address - Country:US
Practice Address - Phone:740-420-8365
Practice Address - Fax:740-420-8340
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002333208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0276964Medicaid
OHE00611Medicare UPIN
OHMO414771Medicare ID - Type Unspecified