Provider Demographics
NPI:1861444986
Name:FAZEL, SHAWN (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
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 1:2451 S ROANOKE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2369
Mailing Address - Country:US
Mailing Address - Phone:401-529-6111
Mailing Address - Fax:
Practice Address - Street 1:5102 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1703
Practice Address - Country:US
Practice Address - Phone:623-848-5180
Practice Address - Fax:623-848-5178
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41504207R00000X
RIRI11743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RII30959Medicare UPIN