Healthcare Provider Details

I. General information

NPI: 1881647352
Provider Name (Legal Business Name): ALI M GHAFFARI SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 WEST 14TH ST
CLOVIS NM
88101
US

IV. Provider business mailing address

815 W 14TH ST
CLOVIS NM
88101-5514
US

V. Phone/Fax

Practice location:
  • Phone: 505-762-6492
  • Fax: 505-762-9981
Mailing address:
  • Phone: 505-762-6492
  • Fax: 505-762-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81202
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: