Provider Demographics
NPI:1023647245
Name:BAHARLOO, AMIR
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:BAHARLOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CROSSROADS DR STE 15
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5479
Mailing Address - Country:US
Mailing Address - Phone:410-363-4343
Mailing Address - Fax:410-356-6373
Practice Address - Street 1:20 CROSSROADS DR STE 15
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5479
Practice Address - Country:US
Practice Address - Phone:410-363-4343
Practice Address - Fax:410-356-6373
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PASC007329213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program