Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 113525 | MO |
NPI | 1104853316 |
---|---|
Provider Name | David Zolfaghari |
First Address | Springfield, MO 65808-9007 |
Second Address | Springfield, MO 65807-5209 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2006 |
Last Update Date | 05/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
110970 | BLUE CROSS/BLUE SHIELD (01) | |
209753201 | (05) | MO |
G55028 | (02) |