Provider Demographics
NPI:1992459655
Name:MOHAGHEGH POOR, SEYED MOHAMMAD (MD, FRCSC)
Entity type:Individual
Prefix:
First Name:SEYED MOHAMMAD
Middle Name:
Last Name:MOHAGHEGH POOR
Suffix:
Gender:M
Credentials:MD, FRCSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-1150
Mailing Address - Country:US
Mailing Address - Phone:802-847-0000
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.143580208800000X
VT042.0017875208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0494682Medicaid