Provider Demographics
NPI:1972562593
Name:GOUDARZI, KAMRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMRAN
Middle Name:
Last Name:GOUDARZI
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 1:710 MILITARY CUTOFF RD STE 130
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-2382
Mailing Address - Country:US
Mailing Address - Phone:910-769-3084
Mailing Address - Fax:910-769-6023
Practice Address - Street 1:710 MILITARY CUTOFF RD STE 130
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-2382
Practice Address - Country:US
Practice Address - Phone:910-769-3084
Practice Address - Fax:910-769-6023
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25503208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8936503Medicaid
NCB82769Medicare UPIN
NC2333009Medicare PIN