Provider Demographics
NPI:1437957792
Name:HASSANPOUR, OMID ALI (MD)
Entity type:Individual
Prefix:DR
First Name:OMID ALI
Middle Name:
Last Name:HASSANPOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 E 16TH AVE STE A&B
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-1776
Mailing Address - Country:US
Mailing Address - Phone:229-273-8881
Mailing Address - Fax:
Practice Address - Street 1:602 E 16TH AVE STE A&B
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-1776
Practice Address - Country:US
Practice Address - Phone:229-273-8881
Practice Address - Fax:229-273-8985
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA18064390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician