Basic Information
Provider Information | |||||||||
NPI: | 1386063816 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAVAKOLI | ||||||||
FirstName: | VAHID | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TAVAKOLI | ||||||||
OtherFirstName: | VAHID | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1001 BELLEFONTAINE AVE | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458042800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199984575 | ||||||||
FaxNumber: | 4199984586 | ||||||||
Practice Location | |||||||||
Address1: | 1003 BELLEFONTAINE AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458041803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192245915 | ||||||||
FaxNumber: | 4192245918 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2014 | ||||||||
LastUpdateDate: | 09/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35.139298 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.