Provider Demographics
NPI:1376592105
Name:FAZEL, NASIM (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:NASIM
Middle Name:
Last Name:FAZEL
Suffix:
Gender:F
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 C ST
Mailing Address - Street 2:STE. 1300
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3300
Mailing Address - Country:US
Mailing Address - Phone:916-734-6876
Mailing Address - Fax:916-442-5702
Practice Address - Street 1:3301 C ST
Practice Address - Street 2:STE. 1300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3300
Practice Address - Country:US
Practice Address - Phone:916-734-6876
Practice Address - Fax:916-442-5702
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83700207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH97966Medicare UPIN