Provider Demographics
NPI:1902981418
Name:BAKHTIARI, GHOLAM R
Entity Type:Individual
Prefix:DR
First Name:GHOLAM
Middle Name:R
Last Name:BAKHTIARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 JESSE HILL JR DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303
Mailing Address - Country:US
Mailing Address - Phone:770-931-3227
Mailing Address - Fax:
Practice Address - Street 1:41 JESSE HILL JR DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2607
Practice Address - Country:US
Practice Address - Phone:404-688-2211
Practice Address - Fax:404-688-2226
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist