Provider Demographics
NPI:1942236807
Name:GHOLAMI, AMIR SASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMIR
Middle Name:SASAN
Last Name:GHOLAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:10060 REGENCY CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3732
Practice Address - Country:US
Practice Address - Phone:402-354-1530
Practice Address - Fax:402-354-1535
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007026338207R00000X
NE25192207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731742Medicaid
IA1942236807Medicaid
NE099099044Medicare PIN