Basic Information
| Provider Information | |||||||||
| NPI: | 1255893483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARZAM | ||||||||
| FirstName: | KHASHAYAR | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193847222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193847222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2019 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/07/2019 | ||||||||
| NPIReactivationDate: | 11/26/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | R-11496 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0123917 | 05 | IA | MEDICAID | R-11496 | 01 | IA | BOARD OF MEDICINE | OTHER |