Basic Information
| Provider Information | |||||||||
| NPI: | 1841678307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARSHAD | ||||||||
| FirstName: | KAYVEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 43160 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857333160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 12480 N RANCHO VISTOSO BLVD STE 180 | ||||||||
| Address2: | |||||||||
| City: | ORO VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857551994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207424008 | ||||||||
| FaxNumber: | 5207424280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2015 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R74993 | AZ | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207R00000X | R74993 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207LP2900X | 59113 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 599366 | 05 | AZ | MEDICAID |