Provider Demographics
NPI:1740324706
Name:FARZANEGAN, FRED (PH D)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:FARZANEGAN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3538
Mailing Address - Country:US
Mailing Address - Phone:813-785-5577
Mailing Address - Fax:
Practice Address - Street 1:82 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3538
Practice Address - Country:US
Practice Address - Phone:813-785-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3572103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73197Medicare ID - Type Unspecified