Provider Demographics
NPI:1306017983
Name:RAZI, MARIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:RAZI
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 1:1301 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2122
Mailing Address - Country:US
Mailing Address - Phone:817-250-4906
Mailing Address - Fax:
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101725207R00000X
TXN9482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAY912XMedicare PIN