Healthcare Provider Details

I. General information

NPI: 1114312980
Provider Name (Legal Business Name): KAIHAN FAKHAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 NICOLLET AVE S
BLOOMINGTON MN
55420-2824
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-541-2800
  • Fax: 952-886-7015
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number69906
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: