Provider Demographics
NPI:1194984872
Name:MIRHASSAN FARIVAR, MD, PA
Entity type:Organization
Organization Name:MIRHASSAN FARIVAR, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRHASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-587-8888
Mailing Address - Street 1:PO BOX 17650
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-0650
Mailing Address - Country:US
Mailing Address - Phone:210-587-8888
Mailing Address - Fax:210-587-8889
Practice Address - Street 1:414 NAVARRO ST
Practice Address - Street 2:1033
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2516
Practice Address - Country:US
Practice Address - Phone:210-587-8888
Practice Address - Fax:210-587-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3465207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196762201Medicaid
TX00Z679Medicare PIN