Provider Demographics
NPI:1932138203
Name:SHAH-HOSSEINI, BAHRAM (MD)
Entity Type:Individual
Prefix:
First Name:BAHRAM
Middle Name:
Last Name:SHAH-HOSSEINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BARRY
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:30 BRIARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1003
Mailing Address - Country:US
Mailing Address - Phone:401-453-3433
Mailing Address - Fax:401-333-3359
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:SUITE 510
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-453-3433
Practice Address - Fax:401-453-0695
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD04758207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD04758OtherSTATE LICENSE
RIAS6192051OtherDEA
RIMD04758OtherSTATE LICENSE