Healthcare Provider Details

I. General information

NPI: 1154732030
Provider Name (Legal Business Name): SIAVOSH VAFADARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W HENDERSON ST
CLEBURNE TX
76033-5100
US

IV. Provider business mailing address

1301 W HENDERSON ST
CLEBURNE TX
76033-5100
US

V. Phone/Fax

Practice location:
  • Phone: 817-558-3937
  • Fax: 817-422-0862
Mailing address:
  • Phone: 817-558-3937
  • Fax: 817-422-0862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10050812
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR5948
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: