Provider Demographics
NPI:1700922424
Name:FAZELI, ALEX POOYA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:POOYA
Last Name:FAZELI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9730 RESEARCH DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4327
Mailing Address - Country:US
Mailing Address - Phone:310-570-8175
Mailing Address - Fax:
Practice Address - Street 1:68 DISCOVERY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3105
Practice Address - Country:US
Practice Address - Phone:310-570-8175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79323208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA79323AMedicare PIN