Provider Demographics
NPI:1639801277
Name:BAZEGHI, JOSEPH (PSS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BAZEGHI
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:BAZEGHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSS
Mailing Address - Street 1:12540 SW MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6198
Mailing Address - Country:US
Mailing Address - Phone:503-906-9995
Mailing Address - Fax:
Practice Address - Street 1:12540 SW MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6198
Practice Address - Country:US
Practice Address - Phone:503-906-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106879175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist