Provider Demographics
NPI:1497732887
Name:FAZELI, POUNEH KHADEJEH (MD)
Entity Type:Individual
Prefix:DR
First Name:POUNEH
Middle Name:KHADEJEH
Last Name:FAZELI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOTHROP STREET
Mailing Address - Street 2:BST W1061
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213
Mailing Address - Country:US
Mailing Address - Phone:412-586-9700
Mailing Address - Fax:
Practice Address - Street 1:3601 5TH AVE
Practice Address - Street 2:SUITE 3B
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3403
Practice Address - Country:US
Practice Address - Phone:412-586-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230492207R00000X
MA227372207RE0101X
PAMD468466207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI37081Medicare UPIN