Provider Demographics
NPI:1184771362
Name:FAZELI, FARZAD (DO)
Entity type:Individual
Prefix:DR
First Name:FARZAD
Middle Name:
Last Name:FAZELI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9209 ELAM RD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-4179
Mailing Address - Country:US
Mailing Address - Phone:214-309-0100
Mailing Address - Fax:214-309-0029
Practice Address - Street 1:9209 ELAM RD
Practice Address - Street 2:SUITE #102
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4179
Practice Address - Country:US
Practice Address - Phone:214-309-0100
Practice Address - Fax:214-309-0029
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B34XMedicare ID - Type Unspecified
TXC15593Medicare UPIN