Provider Demographics
NPI:1912930975
Name:BORHANI, HESAMODIN (MD)
Entity Type:Individual
Prefix:
First Name:HESAMODIN
Middle Name:
Last Name:BORHANI
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 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:1707 E 9TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-2641
Practice Address - Country:US
Practice Address - Phone:660-339-8500
Practice Address - Fax:660-339-8507
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1912930975Medicaid
MO208478016Medicaid
G37733Medicare UPIN
MO208478016Medicaid
MO7769598BMedicare PIN