Basic Information
Provider Information | |||||||||
NPI: | 1205009461 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | G.B. HAERI M D INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GHOL B HAERI-GHARAVI M.D. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22 | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933020022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6613357755 | ||||||||
FaxNumber: | 6613357766 | ||||||||
Practice Location | |||||||||
Address1: | 4545 STOCKDALE HWY STE A | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933092024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6618344812 | ||||||||
FaxNumber: | 6613357766 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2008 | ||||||||
LastUpdateDate: | 04/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAERI-GHARAVI | ||||||||
AuthorizedOfficialFirstName: | GHOL | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT/SOLE PROPRIETOR | ||||||||
AuthorizedOfficialTelephone: | 6613357755 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A38702 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1447220017 | 01 | CA | INDIVIDUAL NPI | OTHER |