Provider Demographics
NPI:1215081112
Name:FAZELI, FLORA (MD)
Entity type:Individual
Prefix:MRS
First Name:FLORA
Middle Name:
Last Name:FAZELI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 BLANKENSHIP RD
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-5101
Mailing Address - Country:US
Mailing Address - Phone:503-210-4900
Mailing Address - Fax:503-210-4998
Practice Address - Street 1:1750 BLANKENSHIP RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-5101
Practice Address - Country:US
Practice Address - Phone:503-210-4900
Practice Address - Fax:503-210-4998
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL16545174400000X
ORMD27444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist