Provider Demographics
NPI:1174819395
Name:KIANKHOOY FARD, BANAFSHEH (MD)
Entity Type:Individual
Prefix:
First Name:BANAFSHEH
Middle Name:
Last Name:KIANKHOOY FARD
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3831
Mailing Address - Fax:239-343-2301
Practice Address - Street 1:2780 CLEVELAND AVE STE 709
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5857
Practice Address - Country:US
Practice Address - Phone:239-343-3831
Practice Address - Fax:239-343-2301
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1197022080A0000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME119702OtherLICENSE