Healthcare Provider Details

I. General information

NPI: 1235103375
Provider Name (Legal Business Name): KAMBIZ PAHLAVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CENTURY DRIVE
WORCESTER MA
01606
US

IV. Provider business mailing address

100 CENTURY DRIVE
WORCESTER MA
01606
US

V. Phone/Fax

Practice location:
  • Phone: 844-319-0000
  • Fax: 774-701-0950
Mailing address:
  • Phone: 844-319-0000
  • Fax: 774-701-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number33832
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3655
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number44808
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: