Provider Demographics
NPI:1053010488
Name:FAKHRSHAFAEI, KAMRON MANOUCHEHR
Entity type:Individual
Prefix:
First Name:KAMRON
Middle Name:MANOUCHEHR
Last Name:FAKHRSHAFAEI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11520 CEDAR VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170
Mailing Address - Country:US
Mailing Address - Phone:405-761-5575
Mailing Address - Fax:
Practice Address - Street 1:120 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:OK
Practice Address - Zip Code:73669
Practice Address - Country:US
Practice Address - Phone:580-661-3488
Practice Address - Fax:580-661-3488
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator