Healthcare Provider Details

I. General information

NPI: 1487867958
Provider Name (Legal Business Name): KAVEH OFOGH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CONCOURSE BLVD SUITE# 210
GLEN ALLEN VA
23059
US

IV. Provider business mailing address

301 CONCOURSE BLVD SUITE# 210
GLEN ALLEN VA
23059
US

V. Phone/Fax

Practice location:
  • Phone: 804-433-1041
  • Fax: 804-433-1050
Mailing address:
  • Phone: 804-433-1041
  • Fax: 804-433-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number01011052243
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: