Provider Demographics
NPI:1043298391
Name:DJAFARI, FARDIN (MD)
Entity type:Individual
Prefix:
First Name:FARDIN
Middle Name:
Last Name:DJAFARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4320
Mailing Address - Country:US
Mailing Address - Phone:940-687-4700
Mailing Address - Fax:940-687-5000
Practice Address - Street 1:1631 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4320
Practice Address - Country:US
Practice Address - Phone:940-687-4700
Practice Address - Fax:940-687-5000
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0134207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0421737-02Medicaid
TXTXB115932Medicare PIN