Basic Information
Provider Information | |||||||||
NPI: | 1649271925 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GASHTI | ||||||||
FirstName: | SEYED-MOJTABA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3467 W HILLSBORO BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | DEERFIELD BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334429873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5614833989 | ||||||||
FaxNumber: | 7542275792 | ||||||||
Practice Location | |||||||||
Address1: | 3467 W HILLSBORO BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334429473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5614833989 | ||||||||
FaxNumber: | 7542275792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2005 | ||||||||
LastUpdateDate: | 11/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB06746000 | NJ | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 239940 | NY | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0129X | H0062393 | MD | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | OS14009 | FL | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 020127500 | 05 | FL |   | MEDICAID | 7978103 | 05 | NJ |   | MEDICAID |