Provider Demographics
NPI:1891059689
Name:FAKHORI, NINA LOPEZ (DO)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:LOPEZ
Last Name:FAKHORI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 260 SUDLAGER 301
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112
Mailing Address - Country:US
Mailing Address - Phone:314-590-2300
Mailing Address - Fax:
Practice Address - Street 1:SUDLAGER 301, BLDG 260
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:US
Practice Address - Phone:314-590-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS1613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN