1952782294 NPI number — DR. OMID FALLAH MEHDIPOUR FARASHTAMI

Table of content: DR. OMID FALLAH MEHDIPOUR FARASHTAMI (NPI 1952782294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952782294 NPI number — DR. OMID FALLAH MEHDIPOUR FARASHTAMI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FALLAH MEHDIPOUR FARASHTAMI
Provider First Name:
OMID
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1952782294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13201 LEGENDARY DR
Provider Second Line Business Mailing Address:
APT 4302
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78727-4023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-776-1933
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7401 W WASHINGTON AVE APT 2047
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89128-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-776-1933
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 31764 , 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)





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