Provider Demographics
NPI:1659308047
Name:FANOUS, ELIA (MD)
Entity Type:Individual
Prefix:
First Name:ELIA
Middle Name:
Last Name:FANOUS
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 1:3501 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3636
Mailing Address - Country:US
Mailing Address - Phone:972-256-3700
Mailing Address - Fax:972-258-9887
Practice Address - Street 1:3501 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3636
Practice Address - Country:US
Practice Address - Phone:972-256-3700
Practice Address - Fax:972-258-9887
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1088207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AU310OtherBLUE CROSS BLUE SHIELD
TX188387801Medicaid
8F8636Medicare PIN