Basic Information
Provider Information | |||||||||
NPI: | 1285746875 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAGHERI | ||||||||
FirstName: | SHOLEH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3002 | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986320302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604142048 | ||||||||
FaxNumber: | 3605756749 | ||||||||
Practice Location | |||||||||
Address1: | 1615 DELAWARE ST | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986322310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604142730 | ||||||||
FaxNumber: | 3604142739 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 02/05/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 216509 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD00047589 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | MD00047589 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 8477382 | 05 | WA |   | MEDICAID | 8944123 | 01 | WA | CRIME VICTIMS | OTHER | P00392543 | 01 |   | RAILROAD MEDICARE | OTHER | 0219444 | 01 | WA | LABOR & INDUSTRIES | OTHER | 02529362 | 05 | NY |   | MEDICAID |