Provider Demographics
NPI:1346597804
Name:MOSTAFAVI NAEINI, BARDYA
Entity type:Individual
Prefix:
First Name:BARDYA
Middle Name:
Last Name:MOSTAFAVI NAEINI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 CENTER POINT LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35634-2012
Mailing Address - Country:US
Mailing Address - Phone:256-229-6262
Mailing Address - Fax:
Practice Address - Street 1:2107 CLOYD BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1503
Practice Address - Country:US
Practice Address - Phone:773-242-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.33091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine