Healthcare Provider Details

I. General information

NPI: 1326307794
Provider Name (Legal Business Name): BANAFSHEH BAHARLOO DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 CHIMNEY ROCK RD
HOUSTON TX
77035-2905
US

IV. Provider business mailing address

11515 CHIMNEY ROCK RD
HOUSTON TX
77035-2905
US

V. Phone/Fax

Practice location:
  • Phone: 713-728-3117
  • Fax: 713-728-2212
Mailing address:
  • Phone: 713-728-3117
  • Fax: 713-728-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number2095
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2095
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: