Healthcare Provider Details

I. General information

NPI: 1649733254
Provider Name (Legal Business Name): GILAD MIZRAHI GHANBARI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 PLANTATION ST # 559
WORCESTER MA
01605-2376
US

IV. Provider business mailing address

PO BOX 22239
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax: 702-977-1496
Mailing address:
  • Phone: 201-654-6397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOP61079628
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number080683
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1026572
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number307681
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: