Provider Demographics
NPI:1659418275
Name:GHOFRANY, FERESHTEH (MD)
Entity Type:Individual
Prefix:
First Name:FERESHTEH
Middle Name:
Last Name:GHOFRANY
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 1951
Mailing Address - Street 2:SAINT RAPHAEL FACULTY PHYSICIANS
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-1951
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:1450 CHAPEL ST.
Practice Address - Street 2:SAINT RAPHAEL FACULTY PHYSICIANS
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015813208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT370001701Medicare PIN
B83371Medicare UPIN