Basic Information
| Provider Information | |||||||||
| NPI: | 1992012173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODARZI | ||||||||
| FirstName: | AHMAD | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134410006 | ||||||||
| FaxNumber: | 7137902727 | ||||||||
| Practice Location | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134410006 | ||||||||
| FaxNumber: | 7137902727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2010 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 246560 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | P2861 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | P2861 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 338330904 | 01 | TX | CSHCN SERVICES PROGRAM | OTHER | 8FC773 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 338330902 | 05 | TX | MEDICAID | 338330903 | 05 | TX | MEDICAID | 8FX368 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |