Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207U00000X | Nuclear Medicine Specialist | 41198 | AZ |
NPI | 1235146648 |
---|---|
Provider Name | Homayoun Modarresifar |
First Address | Johnson City, TN 37604-6024 |
Second Address | Johnson City, TN 37604-6024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 13/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MD0000046850 | TENNESSEE MEDICAL LICENSE (01) | TN |