Provider Demographics
NPI:1588646228
Name:GHOFRANI, MOHIEDEAN (MD)
Entity Type:Individual
Prefix:
First Name:MOHIEDEAN
Middle Name:
Last Name:GHOFRANI
Suffix:
Gender:M
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:PO BOX 873097
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-3097
Mailing Address - Country:US
Mailing Address - Phone:360-210-7924
Mailing Address - Fax:
Practice Address - Street 1:SW WASHINGTON MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98668
Practice Address - Country:US
Practice Address - Phone:360-514-2116
Practice Address - Fax:360-514-6517
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043544207ZP0102X
WAMD00046467207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I46663Medicare UPIN