Provider Demographics
NPI:1790069847
Name:GHADERI, IMAN (MD)
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:GHADERI
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 1:3950 S COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85714-2099
Mailing Address - Country:US
Mailing Address - Phone:919-966-4131
Mailing Address - Fax:
Practice Address - Street 1:3950 S COUNTRY CLUB RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-2099
Practice Address - Country:US
Practice Address - Phone:919-966-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48757208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery