Provider Demographics
NPI:1689645632
Name:GHADERI, MAHMOUD (DO)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:GHADERI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 W COHAWKIN RD STE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020-1145
Mailing Address - Country:US
Mailing Address - Phone:856-423-7700
Mailing Address - Fax:856-423-0823
Practice Address - Street 1:1501 LANSDOWNE AVE STE 209
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1333
Practice Address - Country:US
Practice Address - Phone:484-494-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-29
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008674L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018130520010Medicaid
PAH09508Medicare UPIN
PA042994Medicare ID - Type Unspecified