Provider Demographics
NPI:1154405934
Name:AGHDASI, IRAJ (MD)
Entity type:Individual
Prefix:
First Name:IRAJ
Middle Name:
Last Name:AGHDASI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 MAIN ST
Mailing Address - Street 2:SUITE # 24
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1612
Mailing Address - Country:US
Mailing Address - Phone:781-331-8584
Mailing Address - Fax:781-331-8585
Practice Address - Street 1:851 MAIN ST
Practice Address - Street 2:SUITE # 24
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1612
Practice Address - Country:US
Practice Address - Phone:781-331-8584
Practice Address - Fax:781-331-8585
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2067463Medicaid
MAC03039Medicare ID - Type Unspecified
MA2067463Medicaid