Provider Demographics
NPI:1598081028
Name:FAZEL, RAHIM (DO)
Entity Type:Individual
Prefix:DR
First Name:RAHIM
Middle Name:
Last Name:FAZEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 OHARE PKWY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4005
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:881 OHARE PKWY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4005
Practice Address - Country:US
Practice Address - Phone:949-263-8620
Practice Address - Fax:800-409-7005
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0102022085R0202X
ORDO1698892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500683931Medicaid
OH1669562864Medicaid
OH1669562864Medicaid