Provider Demographics
NPI:1689632945
Name:REFAEIAN, MANOUCHEHR (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOUCHEHR
Middle Name:
Last Name:REFAEIAN
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 1:10412 VISTA DEL SOL DR
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7946
Mailing Address - Country:US
Mailing Address - Phone:915-593-9300
Mailing Address - Fax:915-593-9310
Practice Address - Street 1:10412 VISTA DEL SOL DR
Practice Address - Street 2:SUITE 1-B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7946
Practice Address - Country:US
Practice Address - Phone:915-593-9300
Practice Address - Fax:915-593-9310
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6684208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031059101Medicaid
5073416OtherAETNA
TX8A8950OtherBLUE CROSS BLUE SHIELD
TX031059101Medicaid
TXG33479Medicare UPIN