Provider Demographics
NPI:1780785311
Name:GOLESTANEH, FAZLOLLAH (MD)
Entity type:Individual
Prefix:MR
First Name:FAZLOLLAH
Middle Name:
Last Name:GOLESTANEH
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:PO BOX 2300
Mailing Address - Street 2:SAM RADIOLOGY SERVICES, LLC
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08362-2300
Mailing Address - Country:US
Mailing Address - Phone:856-507-9512
Mailing Address - Fax:856-507-9516
Practice Address - Street 1:66 TANNER STREET
Practice Address - Street 2:SAM RADIOLOGY SERVICES, LLC
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033
Practice Address - Country:US
Practice Address - Phone:856-507-9512
Practice Address - Fax:856-507-9516
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA031099002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2323206Medicaid
NJG0108278Medicare ID - Type Unspecified
C57357Medicare UPIN