Provider Demographics
NPI:1699725606
Name:GHAFARI, GEORGES B (MD)
Entity type:Individual
Prefix:
First Name:GEORGES
Middle Name:B
Last Name:GHAFARI
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 1:24211 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1190
Mailing Address - Country:US
Mailing Address - Phone:586-498-0440
Mailing Address - Fax:586-498-0401
Practice Address - Street 1:24211 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1190
Practice Address - Country:US
Practice Address - Phone:586-498-0440
Practice Address - Fax:586-498-0401
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407083207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10Other10
MI3380370Medicaid
MIF28185Medicare UPIN