Basic Information
| Provider Information | |||||||||
| NPI: | 1790993483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAZEL | ||||||||
| FirstName: | POORYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6151 S YALE AVE | ||||||||
| Address2: | SUITE A-100 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184948500 | ||||||||
| FaxNumber: | 9183075578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N2495 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | AA22180774308 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RI0011X | 30464 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 207296902 | 05 | TX | MEDICAID |