Provider Demographics
NPI:1710096839
Name:GHASEMZADEH, ALI (MD)
Entity Type:Individual
Prefix:MR
First Name:ALI
Middle Name:
Last Name:GHASEMZADEH
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 577
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121
Mailing Address - Country:US
Mailing Address - Phone:937-378-9090
Mailing Address - Fax:937-378-0102
Practice Address - Street 1:5062 STATE ROUTE 125
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-9561
Practice Address - Country:US
Practice Address - Phone:937-378-9090
Practice Address - Fax:937-378-0102
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080480207RC0000X
KY38551207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0904701OtherMEDICAID
KY64073497OtherMEDICAID
OH2291738Medicaid
F40123Medicare UPIN
OH4068961Medicare PIN