Healthcare Provider Details

I. General information

NPI: 1952714669
Provider Name (Legal Business Name): AMIN FAROKHRANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W CAPITOL DR
MILWAUKEE WI
53212-1185
US

IV. Provider business mailing address

75 MOUNT AUBURN ST
CAMBRIDGE MA
02138-4960
US

V. Phone/Fax

Practice location:
  • Phone: 414-727-6320
  • Fax:
Mailing address:
  • Phone: 617-495-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number1019585
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301106062
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036147889
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: