Provider Demographics
NPI:1225002603
Name:POOR, HOOSHANG
Entity type:Individual
Prefix:DR
First Name:HOOSHANG
Middle Name:
Last Name:POOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HOOSHANG
Other - Middle Name:
Other - Last Name:POOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:22 LIBERTY DR UNIT 6F
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1325
Mailing Address - Country:US
Mailing Address - Phone:617-244-1669
Mailing Address - Fax:617-244-1669
Practice Address - Street 1:22 LIBERTY DR UNIT 6F
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-1325
Practice Address - Country:US
Practice Address - Phone:617-244-1669
Practice Address - Fax:617-244-1669
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50091207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6191177Medicaid
J04269Medicare ID - Type Unspecified
MAD88382Medicare UPIN