Provider Demographics
NPI:1881642940
Name:FAEZ-REZVANI, FARNOUSH F (DPM)
Entity Type:Individual
Prefix:
First Name:FARNOUSH
Middle Name:F
Last Name:FAEZ-REZVANI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 W. GRAND PKWY. S.
Mailing Address - Street 2:G-120
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-8300
Mailing Address - Country:US
Mailing Address - Phone:866-950-3627
Mailing Address - Fax:800-652-8206
Practice Address - Street 1:1450 W. GRAND PKWY. S.
Practice Address - Street 2:G-120
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-8300
Practice Address - Country:US
Practice Address - Phone:866-950-3627
Practice Address - Fax:800-652-8206
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1724213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0001MROtherBCBS
TX173402203Medicaid
TX173402201Medicaid
TX173402202Medicaid
TXP00452024OtherRAIL RD. MEDICARE
TX173402205Medicaid
TX173402206Medicaid
TX611783Medicare PIN
TX8F3907Medicare PIN
TX8F3888Medicare PIN
TX173402203Medicaid
TX173402206Medicaid
TX611782Medicare PIN
TX611781Medicare PIN