Provider Demographics
NPI:1205803814
Name:GHODSI, SEYED ABDOLREZA (MD)
Entity type:Individual
Prefix:
First Name:SEYED
Middle Name:ABDOLREZA
Last Name:GHODSI
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 1:416 COLEGATE DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-9549
Mailing Address - Country:US
Mailing Address - Phone:740-568-4814
Mailing Address - Fax:740-374-3165
Practice Address - Street 1:807 FARSON ST STE 136
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-1068
Practice Address - Country:US
Practice Address - Phone:740-423-3634
Practice Address - Fax:740-423-3635
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20199207T00000X
OH35.078655207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6100039000Medicaid
OH2209676Medicaid
WV6100039000Medicaid
WVGH4023635Medicare PIN
OH2209676Medicaid
OHGH4023633Medicare PIN