THANAWALLA, FARID ABDULREHMAN (MD)

Provider Demographics

• NPI: 1770558496
• Name: THANAWALLA, FARID ABDULREHMAN (MD)
• Entity type: Individual
• First Name: FARID
• Middle Name: ABDULREHMAN
• Last Name: THANAWALLA
• Gender: M
• Credentials: MD
• Mailing Address - Street 1: 919 CONFERENCE DR
• Mailing Address - Street 2: SUITE #4, BOX 167
• Mailing Address - City: GOODLETTSVILLE
• Mailing Address - State: TN
• Mailing Address - Zip Code: 37072-1924
• Mailing Address - Country: US
• Mailing Address - Phone: 615-788-9324
• Practice Address - Street 1: 919 CONFERENCE DR STE 4
• Practice Address - City: GOODLETTSVILLE
• Practice Address - State: TN
• Practice Address - Zip Code: 37072-1924
• Practice Address - Country: US
• Practice Address - Phone: 615-788-9324
• Is Sole Proprietor?: No
• Enumeration Date: 2006-02-17
• Last Update Date: 2023-01-19

Provider Licenses

State	License ID	Taxonomies
MA	217086	2085R0202X, 2085R0204X
NE	24890	2085R0202X, 2085R0204X
CO	56250	2085R0202X
KS	04-39312	2085R0202X
HI	MD18855	2085R0202X
TN	54593	2085R0204X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	2085R0204X	Allopathic & Osteopathic Physicians	Radiology	Vascular & Interventional Radiology
No	2085R0202X	Allopathic & Osteopathic Physicians	Radiology	Diagnostic Radiology

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MT	1770558496	Medicaid
IA	1770558496	Medicaid
OK	200659440A	Medicaid
MA	2015757	Medicaid
NM	87881730	Medicaid
SD	1770558496	Medicaid
AZ	191281	Medicaid
MA	A35829	Other	MEDICARE ID
KS	201141130A	Medicaid
CO	82653844	Medicaid
NE	$$$$$$$$$	Medicaid
NE	$$$$$$$$$11	Medicaid
CO	82653844	Medicaid
NE	$$$$$$$$$14	Medicaid
NE	$$$$$$$$$06	Medicaid
OK	200659440A	Medicaid
IA	1770558496	Medicaid
AZ	191281	Medicaid
NE	$$$$$$$$$09	Medicaid
NE	$$$$$$$$$12	Medicaid
NE	NA1215072	Medicare PIN
MA	A35829	Other	MEDICARE ID
NE	$$$$$$$$$14	Medicaid
KS	201141130A	Medicaid
AZ	191281	Medicaid
NE	NA1214072	Medicare PIN
KS	KA3249080	Medicare PIN
NE	NA2517078	Medicare PIN
CO	498601ZLJ3	Medicare PIN