Healthcare Provider Details

I. General information

NPI: 1184689515
Provider Name (Legal Business Name): ROHAM MOFTAKHAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RICHLAND MEDICAL PARK DR SUITE 310
COLUMBIA SC
29203-6849
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-8323
  • Fax: 803-434-8326
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036-129390
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number37893
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number47499
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: