Provider Demographics
NPI:1295972867
Name:FAZEL, PATRA (OD)
Entity type:Individual
Prefix:
First Name:PATRA
Middle Name:
Last Name:FAZEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3519 NORTHWEST PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-4012
Mailing Address - Country:US
Mailing Address - Phone:214-808-6653
Mailing Address - Fax:214-987-0187
Practice Address - Street 1:4100 W AIRPORT FWY STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5913
Practice Address - Country:US
Practice Address - Phone:972-986-9778
Practice Address - Fax:972-986-5938
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5946TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist