Provider Demographics
NPI:1851754709
Name:GHOORKHANIAN, BORNA REZA
Entity Type:Individual
Prefix:
First Name:BORNA
Middle Name:REZA
Last Name:GHOORKHANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 AUBURN AVE STE 334
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-585-1500
Mailing Address - Fax:513-585-1510
Practice Address - Street 1:2123 AUBURN AVE STE 334
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-585-1500
Practice Address - Fax:513-585-1510
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.135594207R00000X
OH57.027746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0345137Medicaid
KY7100591900Medicaid