1477645364 NPI number — DR. FATTOLLAH NEJAT-BAKHSH DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477645364 NPI number — DR. FATTOLLAH NEJAT-BAKHSH DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEJAT-BAKHSH
Provider First Name:
FATTOLLAH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1477645364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
603 ISOM RD
Provider Second Line Business Mailing Address:
STE # 103
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78216-4455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-340-0333
Provider Business Mailing Address Fax Number:
210-340-0955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
603 ISOM RD
Provider Second Line Business Practice Location Address:
STE # 103
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78216-4455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-340-0333
Provider Business Practice Location Address Fax Number:
210-340-0955
Provider Enumeration Date:
09/28/2006

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: 111N00000X , with the licence number:  9120 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7067472 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4370625 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 656439 . This is a "ACN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 606413 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 155508801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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