Provider Demographics
NPI:1326307794
Name:BAHARLOO, BANAFSHEH (DPM)
Entity Type:Individual
Prefix:DR
First Name:BANAFSHEH
Middle Name:
Last Name:BAHARLOO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11515 CHIMNEY ROCK RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-2905
Mailing Address - Country:US
Mailing Address - Phone:713-728-3117
Mailing Address - Fax:713-728-2212
Practice Address - Street 1:11515 CHIMNEY ROCK RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-2905
Practice Address - Country:US
Practice Address - Phone:713-728-3117
Practice Address - Fax:713-728-2212
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2095213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344183401Medicaid
TX386617ZLR6Medicare PIN