Provider Demographics
NPI:1013913433
Name:KHAVARI, ALI (MD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:KHAVARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:207-973-8881
Mailing Address - Fax:207-973-8880
Practice Address - Street 1:55 BROADWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5201
Practice Address - Country:US
Practice Address - Phone:207-973-8881
Practice Address - Fax:207-947-5368
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME009535208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME110720099Medicaid
ME072422Medicare ID - Type UnspecifiedRENDERING PROVIDER ID
ME110720099Medicaid