Provider Demographics
NPI:1518330174
Name:FAZEL, MITRA (DC)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:FAZEL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23116 CINCO RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-2891
Mailing Address - Country:US
Mailing Address - Phone:281-347-4444
Mailing Address - Fax:281-347-4445
Practice Address - Street 1:23116 CINCO RANCH BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-2891
Practice Address - Country:US
Practice Address - Phone:281-347-4444
Practice Address - Fax:281-347-4445
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07941111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor