Healthcare Provider Details

I. General information

NPI: 1811457674
Provider Name (Legal Business Name): EDDIE WALID FAKHOURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1 HOSPITAL DR
COLUMBIA MO
65212-3609
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2200
  • Fax:
Mailing address:
  • Phone: 573-884-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2022024150
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number75978
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: