Provider Demographics
NPI:1942278700
Name:KOUSHA, FARAHNAZ (MD)
Entity Type:Individual
Prefix:
First Name:FARAHNAZ
Middle Name:
Last Name:KOUSHA
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:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66201-0838
Mailing Address - Country:US
Mailing Address - Phone:913-469-4244
Mailing Address - Fax:913-469-1939
Practice Address - Street 1:17203 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1859
Practice Address - Country:US
Practice Address - Phone:816-478-5252
Practice Address - Fax:816-478-5251
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004034265207Q00000X
KS30568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR86D899Medicare ID - Type UnspecifiedPROVIDER NUMBER