Provider Demographics
NPI:1316925522
Name:AFSHANG, GHOLAMALI (MD)
Entity type:Individual
Prefix:DR
First Name:GHOLAMALI
Middle Name:
Last Name:AFSHANG
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 1:3249 OAK PARK AVE
Mailing Address - Street 2:RADIOLOGY
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3429
Mailing Address - Country:US
Mailing Address - Phone:708-783-2696
Mailing Address - Fax:708-783-3164
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:METROPOLITAN ADVANCED RADIOLOGY
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-2696
Practice Address - Fax:708-783-3164
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00365615OtherRR MEDICARE
IL36060114Medicaid
IL01615363OtherBLUE CROSS GROUP
IL36060114Medicaid
ILK36056Medicare PIN
ILL91787Medicare ID - Type Unspecified
IL01615363OtherBLUE CROSS GROUP
ILP00365615OtherRR MEDICARE