Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207L00000X | Anesthesiologist | 25MA02956300 | NJ |
NPI | 1003988791 |
---|---|
Provider Name | Mohammed Dastghaib |
First Address | Philadelphia, PA 19182-7944 |
Second Address | East Orange, NJ 07018-2819 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2006 |
Last Update Date | 08/07/2007 |