Provider Demographics
NPI:1043490527
Name:ELIA FANOUS MD PA
Entity type:Organization
Organization Name:ELIA FANOUS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FANOUS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:972-786-0140
Mailing Address - Street 1:3501 N MACARTHUR BLVD
Mailing Address - Street 2:STE 500
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3636
Mailing Address - Country:US
Mailing Address - Phone:972-786-0140
Mailing Address - Fax:
Practice Address - Street 1:3501 N MACARTHUR BLVD
Practice Address - Street 2:STE 500
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3636
Practice Address - Country:US
Practice Address - Phone:972-786-0140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1088207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189357001Medicaid
TX0026QUOtherBLUE CROSS BLUE SHIELD
TX0026QUOtherBLUE CROSS BLUE SHIELD