1689645632 NPI number — MAHMOUD GHADERI DO

Table of content: MAHMOUD GHADERI DO (NPI 1689645632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689645632 NPI number — MAHMOUD GHADERI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHADERI
Provider First Name:
MAHMOUD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1689645632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 W COHAWKIN RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSBORO
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08020-1145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-423-7700
Provider Business Mailing Address Fax Number:
856-423-0823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 LANSDOWNE AVE STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DARBY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19023-1333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-494-5595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2006

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:  OS008674L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018130520010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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