Provider Demographics
NPI:1568423697
Name:GHAFFARI, BITA (MD)
Entity Type:Individual
Prefix:
First Name:BITA
Middle Name:
Last Name:GHAFFARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 DRINKWATER BLVD.
Mailing Address - Street 2:
Mailing Address - City:BAY ST. LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520
Mailing Address - Country:US
Mailing Address - Phone:228-467-8676
Mailing Address - Fax:228-467-8674
Practice Address - Street 1:4433 LEISURE TIME DR.
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3334
Practice Address - Country:US
Practice Address - Phone:228-586-9229
Practice Address - Fax:228-586-9230
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H97806Medicare UPIN
MS512I080087Medicare PIN