Provider Demographics
NPI:1922568245
Name:VAFA FERDOWSIAN DPM, P.A.
Entity Type:Organization
Organization Name:VAFA FERDOWSIAN DPM, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAFA
Authorized Official - Middle Name:N
Authorized Official - Last Name:FERDOWSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:501-327-3668
Mailing Address - Street 1:PO BOX 10607
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0010
Mailing Address - Country:US
Mailing Address - Phone:501-327-3668
Mailing Address - Fax:501-327-3664
Practice Address - Street 1:805 N KENTUCKY AVE STE 3
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2045
Practice Address - Country:US
Practice Address - Phone:870-508-4000
Practice Address - Fax:870-508-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518259498Medicaid