Basic Information
| Provider Information | |||||||||
| NPI: | 1831687755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHANIM | ||||||||
| FirstName: | DAFFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3055 ROSLYN STREET | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205532696 | ||||||||
| FaxNumber: | 7208489050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3055 ROSLYN STREET | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205532696 | ||||||||
| FaxNumber: | 7208489050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/29/2018 | ||||||||
| NPIReactivationDate: | 12/10/2018 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TL.0007036 | CO | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.