1114098696 NPI number — DR. BOBAK AMIR GHAHERI M.D.

Table of content: DR. BOBAK AMIR GHAHERI M.D. (NPI 1114098696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114098696 NPI number — DR. BOBAK AMIR GHAHERI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHAHERI
Provider First Name:
BOBAK
Provider Middle Name:
AMIR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GHAHERI
Provider Other First Name:
BOBBY
Provider Other Middle Name:
AMIR
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1114098696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 NE 20TH AVE STE 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-2895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2801
Provider Business Mailing Address Fax Number:
503-963-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24076 SE STARK ST
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-3373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-488-2600
Provider Business Practice Location Address Fax Number:
503-465-5468
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  MD27404 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8481699 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006246 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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