=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356350805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | G. REZA H FARSAD M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 12/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 N PALM CANYON DR SUITE 103
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-320-3538
-----------------------------------------------------
Fax | 760-320-4579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 N PALM CANYON DR SUITE 103
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-320-3538
-----------------------------------------------------
Fax | 760-320-4579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 00A378650
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A037865
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------