MEDICARE: KAMRAN GOUDARZI SURGICAL PRACTICE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician		NC

General Provider Information

NPI Number	:	1013494400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAMRAN GOUDARZI SURGICAL PRACTICE PC

Provider Business Mailing Address
First Line	:	710 MILITARY CUTOFF RD STE 130
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28405-2382
Country	:	US
Telephone Number	:	910-769-1079
Fax Number	:	910-769-6023

Provider Business Practice Location Address
First Line	:	710 MILITARY CUTOFF RD STE 130
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28405-2382
Country	:	US
Telephone Number	:	910-769-1079
Fax Number	:	910-769-6023

Authorized Official
Title or Position	:	OWNER
Name	:	KAMRAN GOUDARZI
Credential	:	MD
Telephone Number	:	910-769-1079

Provider Enumeration Date	:	07/27/2018
Last Update Date	:	05/14/2020

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