Healthcare Provider Details

I. General information

NPI: 1568423697
Provider Name (Legal Business Name): BITA GHAFFARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 LEISURE TIME DR.
DIAMONDHEAD MS
39525-3334
US

IV. Provider business mailing address

149 DRINKWATER BLVD.
BAY ST. LOUIS MS
39520
US

V. Phone/Fax

Practice location:
  • Phone: 228-586-9229
  • Fax: 228-586-9230
Mailing address:
  • Phone: 228-467-8676
  • Fax: 228-467-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19006
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: