Provider Demographics
NPI:1083454227
Name:FAROUQ, SHAIB OMAR
Entity type:Individual
Prefix:
First Name:SHAIB
Middle Name:OMAR
Last Name:FAROUQ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 RACINE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-6323
Mailing Address - Country:US
Mailing Address - Phone:303-285-0250
Mailing Address - Fax:
Practice Address - Street 1:1525 DALLAS ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-2014
Practice Address - Country:US
Practice Address - Phone:303-285-0250
Practice Address - Fax:303-285-0139
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPHM56347C00000X
CO160810866172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle