Provider Demographics
NPI:1407018021
Name:DAFTARIAN, ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:DAFTARIAN
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 10797
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77842-0797
Mailing Address - Country:US
Mailing Address - Phone:979-774-1377
Mailing Address - Fax:979-774-6147
Practice Address - Street 1:2801 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2544
Practice Address - Country:US
Practice Address - Phone:979-774-1377
Practice Address - Fax:979-774-6147
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3139174400000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX268666YS8WMedicare PIN