Provider Demographics
NPI:1619986650
Name:GHAFFARI, ADEL A
Entity Type:Individual
Prefix:
First Name:ADEL
Middle Name:A
Last Name:GHAFFARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 MULKEY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1132
Mailing Address - Country:US
Mailing Address - Phone:678-642-7039
Mailing Address - Fax:770-475-5385
Practice Address - Street 1:1810 MULKEY RD STE 101
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1132
Practice Address - Country:US
Practice Address - Phone:678-642-7039
Practice Address - Fax:770-475-5385
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00387224OtherRAILROAD MEDICARE
GAP00387224OtherRAILROAD MEDICARE
GA65BBBWKMedicare PIN