Provider Demographics
NPI:1285746875
Name:BAGHERI, SHOLEH (MD)
Entity type:Individual
Prefix:DR
First Name:SHOLEH
Middle Name:
Last Name:BAGHERI
Suffix:
Gender:F
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:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-2730
Practice Address - Fax:360-414-2739
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216509207R00000X
WAMD00047589207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8477382Medicaid
WA8944123OtherCRIME VICTIMS
P00392543OtherRAILROAD MEDICARE
WA0219444OtherLABOR & INDUSTRIES
NY02529362Medicaid
NY02529362Medicaid
WA8944123OtherCRIME VICTIMS