Healthcare Provider Details

I. General information

NPI: 1891059689
Provider Name (Legal Business Name): NINA LOPEZ FAKHORI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 09/05/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUDLAGER 301, BLDG 260
APO AE
09112
US

IV. Provider business mailing address

BLDG 260 SUDLAGER 301
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2300
  • Fax:
Mailing address:
  • Phone: 314-590-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDOS1613
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: