MEDICARE: DR. FARZAD FAZELI D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	H4004	TX

General Provider Information

NPI Number	:	1184771362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FARZAD FAZELI D.O.

Provider Business Mailing Address
First Line	:	9209 ELAM RD
Second Line	:	SUITE #102
City	:	DALLAS
State	:	TX
Zip	:	75217-4179
Country	:	US
Telephone Number	:	214-309-0100
Fax Number	:	214-309-0029

Provider Business Practice Location Address
First Line	:	9209 ELAM RD
Second Line	:	SUITE #102
City	:	DALLAS
State	:	TX
Zip	:	75217-4179
Country	:	US
Telephone Number	:	214-309-0100
Fax Number	:	214-309-0029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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