Basic Information
Provider Information | |||||||||
NPI: | 1790089159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEPEHR | ||||||||
FirstName: | GOLROKH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JAVID | ||||||||
OtherFirstName: | GOLROKH | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8002 | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | NH | ||||||||
PostalCode: | 030798002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009270002 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 235 N PEARL ST | ||||||||
Address2: | DEPT OF PATHOLOGY | ||||||||
City: | BROCKTON | ||||||||
State: | MA | ||||||||
PostalCode: | 023011794 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084273086 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2010 | ||||||||
LastUpdateDate: | 10/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 254213 | MA | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.