Provider Demographics
NPI:1841246220
Name:DAFTARIAN FAMILY PRACTICE P A
Entity Type:Organization
Organization Name:DAFTARIAN FAMILY PRACTICE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AREZU
Authorized Official - Middle Name:
Authorized Official - Last Name:DAFTARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-776-2277
Mailing Address - Street 1:2710 OSLER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2517
Mailing Address - Country:US
Mailing Address - Phone:979-776-2277
Mailing Address - Fax:
Practice Address - Street 1:2710 OSLER BLVD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2517
Practice Address - Country:US
Practice Address - Phone:979-776-2277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W356Medicare ID - Type Unspecified