Healthcare Provider Details

I. General information

NPI: 1245153675
Provider Name (Legal Business Name): MISBAH FAZLANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N AZALEA DR
MADISON MS
39110-8583
US

IV. Provider business mailing address

1013 N AZALEA DR
MADISON MS
39110-8583
US

V. Phone/Fax

Practice location:
  • Phone: 769-361-6113
  • Fax:
Mailing address:
  • Phone: 769-361-6113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number207RN0300X
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: