Provider Demographics
NPI:1871543074
Name:SHAREGHI, GHOLAMREZA (MD)
Entity type:Individual
Prefix:
First Name:GHOLAMREZA
Middle Name:
Last Name:SHAREGHI
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 1:3408 MILLER RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-0001
Mailing Address - Country:US
Mailing Address - Phone:269-720-9702
Mailing Address - Fax:269-350-5030
Practice Address - Street 1:3408 MILLER RD
Practice Address - Street 2:SUITE 301
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001
Practice Address - Country:US
Practice Address - Phone:269-720-9702
Practice Address - Fax:269-350-5030
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000006384OtherPHP
MI0501311531OtherBCBS
MI4645774Medicaid
MI0501200701OtherBLUE CROSS BLUE SHIELD
MI0501311531OtherBCBS
MI200000006384OtherPHP