Provider Demographics
NPI:1154414977
Name:KAKAVANDI, HAMID (DO)
Entity type:Individual
Prefix:
First Name:HAMID
Middle Name:
Last Name:KAKAVANDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0293
Mailing Address - Country:US
Mailing Address - Phone:318-283-3955
Mailing Address - Fax:318-239-8955
Practice Address - Street 1:420 S VINE ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220
Practice Address - Country:US
Practice Address - Phone:318-283-3955
Practice Address - Fax:318-239-8955
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA321115208600000X
IA03405208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14787Medicare ID - Type Unspecified
IAF29954Medicare UPIN