Provider Demographics
NPI:1952782294
Name:FALLAH MEHDIPOUR FARASHTAMI, OMID
Entity Type:Individual
Prefix:DR
First Name:OMID
Middle Name:
Last Name:FALLAH MEHDIPOUR FARASHTAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13201 LEGENDARY DR
Mailing Address - Street 2:APT 4302
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-4023
Mailing Address - Country:US
Mailing Address - Phone:858-776-1933
Mailing Address - Fax:
Practice Address - Street 1:7401 W WASHINGTON AVE APT 2047
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4314
Practice Address - Country:US
Practice Address - Phone:858-776-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX31764122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program