Healthcare Provider Details

I. General information

NPI: 1942278700
Provider Name (Legal Business Name): FARAHNAZ KOUSHA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17203 E 23RD ST S
INDEPENDENCE MO
64057-1859
US

IV. Provider business mailing address

PO BOX 838
SHAWNEE MISSION KS
66201-0838
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-5252
  • Fax: 816-478-5251
Mailing address:
  • Phone: 913-469-4244
  • Fax: 913-469-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2004034265
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30568
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: