MEDICARE: FAKHRI RETINA PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0132X	Ophthalmologic Surgery Clinic/Center

General Provider Information

NPI Number	:	1073374203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAKHRI RETINA PLLC

Provider Business Mailing Address
First Line	:	13406 MEDICAL COMPLEX DR STE 110
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77375-3330
Country	:	US
Telephone Number	:	832-978-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	13406 MEDICAL COMPLEX DR STE 110
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77375-3330
Country	:	US
Telephone Number	:	832-978-2273
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MURTAZA MUSTAFA MANDVIWALA
Credential	:	MD
Telephone Number	:	832-978-2273

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	01/16/2024

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