Provider Demographics
NPI:1821037706
Name:EHSANIPOOR, KAVEH (MD)
Entity Type:Individual
Prefix:
First Name:KAVEH
Middle Name:
Last Name:EHSANIPOOR
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 1:4750 WATERS AVE STE 452
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6235
Mailing Address - Country:US
Mailing Address - Phone:912-350-5909
Mailing Address - Fax:912-350-5914
Practice Address - Street 1:4750 WATERS AVE STE 452
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-5909
Practice Address - Fax:912-350-5914
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020309207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000175458BMedicaid
GA349755OtherWELLCARE
SCG20309Medicaid
GA10064418OtherAMERIGROUP
GA460003037OtherRR MEDICARE
GA000175458CMedicaid
GA460003037OtherRR MEDICARE
GA000175458CMedicaid