Provider Demographics
NPI:1891755484
Name:SABOORTINAT MOFRAD, ALI (MD)
Entity Type:Individual
Prefix:MR
First Name:ALI
Middle Name:
Last Name:SABOORTINAT MOFRAD
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 1051
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28093-1051
Mailing Address - Country:US
Mailing Address - Phone:704-732-0330
Mailing Address - Fax:
Practice Address - Street 1:113 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4407
Practice Address - Country:US
Practice Address - Phone:704-735-1441
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20827174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8959952Medicaid