Provider Demographics
NPI:1881659589
Name:DAFTARIAN, AREZU (MD)
Entity Type:Individual
Prefix:
First Name:AREZU
Middle Name:
Last Name:DAFTARIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI03102305Medicaid
TX8BR013OtherBCBS
TX103102308Medicaid
TX8F9154Medicare PIN
TX8BR013OtherBCBS
TXG82710Medicare UPIN