Basic Information
| Provider Information | |||||||||
| NPI: | 1184689515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOFTAKHAR | ||||||||
| FirstName: | ROHAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034348323 | ||||||||
| FaxNumber: | 8034348326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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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 | 207T00000X | 036-129390 | IL | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 37893 | SC | Y | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 47499 | WI | N | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 378932 | 05 | SC | MEDICAID |