Provider Demographics
NPI:1427275775
Name:ABOLMAALI DAMGHANI, ALIREZA (MD)
Entity type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:ABOLMAALI DAMGHANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALIREZA
Other - Middle Name:ABOLMAALI
Other - Last Name:DAMGHANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1001 S DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5251
Mailing Address - Country:US
Mailing Address - Phone:214-392-7042
Mailing Address - Fax:405-739-0335
Practice Address - Street 1:1001 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5251
Practice Address - Country:US
Practice Address - Phone:214-392-7042
Practice Address - Fax:405-739-0335
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200203110AMedicaid
OKOK401155OtherMEDICARE PTAN