Provider Demographics
NPI:1659322691
Name:BOLOURI, MOHAMMAD R (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:R
Last Name:BOLOURI
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 1:7809 SARDIS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2757
Mailing Address - Country:US
Mailing Address - Phone:704-364-4000
Mailing Address - Fax:704-364-4005
Practice Address - Street 1:7809 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2757
Practice Address - Country:US
Practice Address - Phone:704-364-4000
Practice Address - Fax:704-364-4005
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004003012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCW72384Medicare UPIN
NC2052362Medicare ID - Type Unspecified
SCN0030CMedicaid
NC5903548Medicaid