Healthcare Provider Details

I. General information

NPI: 1356350805
Provider Name (Legal Business Name): G. REZA H FARSAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N PALM CANYON DR SUITE 103
PALM SPRINGS CA
92262-4434
US

IV. Provider business mailing address

1401 N PALM CANYON DR SUITE 103
PALM SPRINGS CA
92262-4434
US

V. Phone/Fax

Practice location:
  • Phone: 760-320-3538
  • Fax: 760-320-4579
Mailing address:
  • Phone: 760-320-3538
  • Fax: 760-320-4579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number00A378650
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA037865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: