Provider Demographics
NPI:1528311123
Name:FARNAZ DANA FAKHARI, MD, PC
Entity type:Organization
Organization Name:FARNAZ DANA FAKHARI, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PROVIDER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARNAZ
Authorized Official - Middle Name:DANA
Authorized Official - Last Name:FAKHARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-344-6487
Mailing Address - Street 1:18380 WILLAMETTE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-1200
Mailing Address - Country:US
Mailing Address - Phone:503-344-6487
Mailing Address - Fax:503-972-1689
Practice Address - Street 1:18380 WILLAMETTE DR STE 201
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-1200
Practice Address - Country:US
Practice Address - Phone:503-344-6487
Practice Address - Fax:503-972-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD157343261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty