Basic Information
| Provider Information | |||||||||
| NPI: | 1528012051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHAZALI | ||||||||
| FirstName: | MASOOD | ||||||||
| MiddleName: | RAHEEM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.B., B.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 32599 | IA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 48814 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 37127 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 37127 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0500666 | 01 | MN | MEDICA | OTHER | 1013385 | 01 | MN | PREFERRED ONE | OTHER | 1528012051 | 05 | MN | MEDICAID | HP21617 | 01 | MN | HEALTHPARTNERS | OTHER | 1762066 | 01 | MN | AMERICA'S PPO | OTHER | 32343300 | 05 | WI | MEDICAID | P00228750 | 01 | MN | RAILROAD MEDICARE | OTHER | 116880C029 | 01 | MN | UCARE | OTHER | 314G7GH | 01 | MN | BCBS OF MN | OTHER |