Provider Demographics
NPI:1649364860
Name:FARYABI, FARZAD (DPM)
Entity type:Individual
Prefix:MR
First Name:FARZAD
Middle Name:
Last Name:FARYABI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 LAKELAND DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-936-3445
Mailing Address - Fax:601-936-7434
Practice Address - Street 1:2475 LAKELAND DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-936-3445
Practice Address - Fax:601-936-7434
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80147213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120443Medicaid
4354890001OtherPALMETTO DME
MS00120443Medicaid
4354890001OtherPALMETTO DME