Provider Demographics
NPI:1902822802
Name:NIA, ARDESHIR FAGHIH (MD)
Entity Type:Individual
Prefix:MR
First Name:ARDESHIR
Middle Name:FAGHIH
Last Name:NIA
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 1:1211 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-7342
Mailing Address - Country:US
Mailing Address - Phone:580-286-4300
Mailing Address - Fax:580-286-5530
Practice Address - Street 1:1211 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7342
Practice Address - Country:US
Practice Address - Phone:580-286-4300
Practice Address - Fax:580-286-5530
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00756955OtherRAILROAD
F98136Medicare UPIN
OKP00756955OtherRAILROAD