Basic Information
| Provider Information | |||||||||
| NPI: | 1407827876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DASTGIR | ||||||||
| FirstName: | GHULAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918025 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328918025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650291 | ||||||||
| FaxNumber: | 3522650279 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867193610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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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 | 2085R0202X | ME0025680 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME25680 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 067105300 | 05 | FL | MEDICAID |