Provider Demographics
NPI:1578825816
Name:GHAFFARIAN, KENN R (DO)
Entity Type:Individual
Prefix:DR
First Name:KENN
Middle Name:R
Last Name:GHAFFARIAN
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 1:10800 KNIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-4200
Mailing Address - Country:US
Mailing Address - Phone:215-612-4963
Mailing Address - Fax:
Practice Address - Street 1:10800 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-4200
Practice Address - Country:US
Practice Address - Phone:215-612-4963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014540390200000X
PAOS017806207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program