MEDICARE: ELIA FANOUS MD

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	207V00000X	Obstetrics & Gynecology Physician	M1088	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8AU310	OTHER	TX	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659308047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIA FANOUS MD

Provider Business Mailing Address
First Line	:	3501 N MACARTHUR BLVD
Second Line	:	SUITE 500
City	:	IRVING
State	:	TX
Zip	:	75062-3636
Country	:	US
Telephone Number	:	972-256-3700
Fax Number	:	972-258-9887

Provider Business Practice Location Address
First Line	:	3501 N MACARTHUR BLVD
Second Line	:	SUITE 500
City	:	IRVING
State	:	TX
Zip	:	75062-3636
Country	:	US
Telephone Number	:	972-256-3700
Fax Number	:	972-258-9887

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	10/07/2008

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Directions to “ ELIA FANOUS MD” Practice Location

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