Healthcare Provider Details

I. General information

NPI: 1467560201
Provider Name (Legal Business Name): MAMAD MIRZA BAGHERI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MOHAMMED MIRZA BAGHERI

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 TRAIL BLVD UNIT 307
NAPLES FL
34108-2834
US

IV. Provider business mailing address

6100 TRAIL BLVD UNIT 307
NAPLES FL
34108-2834
US

V. Phone/Fax

Practice location:
  • Phone: 951-500-7286
  • Fax:
Mailing address:
  • Phone: 951-500-7286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME170386
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: