Provider Demographics
NPI:1336280767
Name:FAZEL, MOHAMMAD R (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:R
Last Name:FAZEL
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:PO BOX 458
Mailing Address - Street 2:107 S AVE M
Mailing Address - City:OLNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76374
Mailing Address - Country:US
Mailing Address - Phone:940-564-3561
Mailing Address - Fax:940-564-5230
Practice Address - Street 1:107 S AVE M
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:TX
Practice Address - Zip Code:76374
Practice Address - Country:US
Practice Address - Phone:940-564-3561
Practice Address - Fax:940-564-5230
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1003208600000X, 208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133873301Medicaid
TX133873301Medicaid
D49595Medicare UPIN