Provider Demographics
NPI:1487144457
Name:BASHIRIMOGHADDAM, AHMAD (DO)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:BASHIRIMOGHADDAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:AHMAD
Other - Middle Name:
Other - Last Name:MOGHADDAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1200 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5868
Mailing Address - Country:US
Mailing Address - Phone:307-352-8320
Mailing Address - Fax:307-352-5345
Practice Address - Street 1:1200 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5868
Practice Address - Country:US
Practice Address - Phone:307-352-8320
Practice Address - Fax:307-352-5345
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WYTL7240207R00000X
WY14727A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program