Provider Demographics
NPI:1588974380
Name:FARDIN DJAFARI MD PLLC
Entity type:Organization
Organization Name:FARDIN DJAFARI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FARDIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DJAFARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-687-4700
Mailing Address - Street 1:1631 11TH STREET
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301
Mailing Address - Country:US
Mailing Address - Phone:940-687-4700
Mailing Address - Fax:940-687-5000
Practice Address - Street 1:1631 11TH STREET
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301
Practice Address - Country:US
Practice Address - Phone:940-687-4700
Practice Address - Fax:940-687-5000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB115931Medicare PIN