Provider Demographics
NPI:1487215950
Name:ABU-FARSAKH, FADI NIAZY (MD)
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:NIAZY
Last Name:ABU-FARSAKH
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 1:3960 MAYFIELD AVE NE APT 2G
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6612
Mailing Address - Country:US
Mailing Address - Phone:504-478-6877
Mailing Address - Fax:
Practice Address - Street 1:1542 TULANE AVE
Practice Address - Street 2:BOX T4M-2
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112
Practice Address - Country:US
Practice Address - Phone:504-478-6877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301507530207RH0002X, 208D00000X, 207RG0300X
390200000X
LA320211390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2503201Medicaid