1447308739 NPI number — JALLEH VAFAI M.D.

Table of content: MATTHEW E OLSON L.M.F.T. (NPI 1013475995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447308739 NPI number — JALLEH VAFAI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAFAI
Provider First Name:
JALLEH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447308739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 E 2ND AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-509-3278
Provider Business Mailing Address Fax Number:
706-509-4608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 TURNER MCCALL BLVD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30165-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-509-5000
Provider Business Practice Location Address Fax Number:
706-509-4608
Provider Enumeration Date:
01/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  045019 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".