Provider Demographics
NPI:1558342618
Name:KOOHESTANI, AMIR (DO)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:KOOHESTANI
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 1:500 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4024
Mailing Address - Country:US
Mailing Address - Phone:704-438-7396
Mailing Address - Fax:704-550-5404
Practice Address - Street 1:500 N 4TH ST
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-4024
Practice Address - Country:US
Practice Address - Phone:704-550-5516
Practice Address - Fax:704-550-5404
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC131XTOtherBCBS
NC89131XTMedicaid
080187671OtherRAIL ROAD MEDICARE
NC131XTOtherBCBS
H67123Medicare UPIN
2401258Medicare ID - Type Unspecified