1053010488 NPI number — KAMRON MANOUCHEHR FAKHRSHAFAEI

Table of content: KAMRON MANOUCHEHR FAKHRSHAFAEI (NPI 1053010488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053010488 NPI number — KAMRON MANOUCHEHR FAKHRSHAFAEI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAKHRSHAFAEI
Provider First Name:
KAMRON
Provider Middle Name:
MANOUCHEHR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053010488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11520 CEDAR VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-761-5575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W. BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMAS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-661-3488
Provider Business Practice Location Address Fax Number:
580-661-3488
Provider Enumeration Date:
02/24/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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