Basic Information
| Provider Information | |||||||||
| NPI: | 1447220017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAERI-GHARAVI | ||||||||
| FirstName: | GHOL | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613357755 | ||||||||
| FaxNumber: | 6613357766 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 STOCKDALE HWY | ||||||||
| Address2: | #A | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613357755 | ||||||||
| FaxNumber: | 6613357766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A38702 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A387020 | 05 | CA | MEDICAID |