Provider Demographics
NPI:1225657349
Name:HAZRATI POUR FARD, NIMA (MD)
Entity Type:Individual
Prefix:MR
First Name:NIMA
Middle Name:
Last Name:HAZRATI POUR FARD
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 1:220 STEUBEN ST
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865-9740
Mailing Address - Country:US
Mailing Address - Phone:607-535-7121
Mailing Address - Fax:
Practice Address - Street 1:220 STEUBEN ST
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865-9740
Practice Address - Country:US
Practice Address - Phone:607-535-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine