Provider Demographics
NPI:1750570842
Name:AFSAHREZVANI, IBRAHIM
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:AFSAHREZVANI
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 1:1312 SW 10TH AVE
Mailing Address - Street 2:APT 305
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-3444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1312 SW 10TH AVE
Practice Address - Street 2:APT 305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-3444
Practice Address - Country:US
Practice Address - Phone:503-238-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion