Provider Demographics
NPI:1790993483
Name:FAZEL, POORYA (MD)
Entity Type:Individual
Prefix:DR
First Name:POORYA
Middle Name:
Last Name:FAZEL
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 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:
Practice Address - Street 1:6151 S YALE AVE
Practice Address - Street 2:SUITE A-100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1907
Practice Address - Country:US
Practice Address - Phone:918-494-8500
Practice Address - Fax:918-307-5578
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2495207R00000X
TXAA22180774308390200000X
OK30464207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207296902Medicaid
TXTXB132523Medicare PIN
TX207296902Medicaid
TXP01121438Medicare PIN