1205009461 NPI number — G.B. HAERI M D INC

Table of content: (NPI 1205009461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205009461 NPI number — G.B. HAERI M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G.B. HAERI M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205009461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93302-0022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-335-7755
Provider Business Mailing Address Fax Number:
661-335-7766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 STOCKDALE HWY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93309-2024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-834-4812
Provider Business Practice Location Address Fax Number:
661-335-7766
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HAERI-GHARAVI
Authorized Official First Name:
GHOL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER/PRESIDENT/SOLE PROPRIETOR
Authorized Official Telephone Number:
661-335-7755

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A38702 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1447220017 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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