Provider Demographics
NPI:1992738983
Name:NIKROOZ, POUNEH MOFRAD (MD)
Entity type:Individual
Prefix:DR
First Name:POUNEH
Middle Name:MOFRAD
Last Name:NIKROOZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:NIKROOZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-918-1934
Mailing Address - Fax:
Practice Address - Street 1:16817 MARVIN RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2196
Practice Address - Country:US
Practice Address - Phone:704-495-6036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401552207RG0100X
NC2004-01552207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901545Medicaid
NC280836Medicare ID - Type Unspecified
NC5901545Medicaid
NCI12417Medicare UPIN