Basic Information
Provider Information | |||||||||
NPI: | 1780676981 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORFAHLI | ||||||||
FirstName: | M | ||||||||
MiddleName: | NIZAR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1250 S WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | VAN WERT | ||||||||
State: | OH | ||||||||
PostalCode: | 458912551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192325279 | ||||||||
FaxNumber: | 4192380692 | ||||||||
Practice Location | |||||||||
Address1: | 1250 S WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | VAN WERT | ||||||||
State: | OH | ||||||||
PostalCode: | 458912551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192388642 | ||||||||
FaxNumber: | 4192388617 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2005 | ||||||||
LastUpdateDate: | 02/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 01074233 | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 01074233 | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 35062579O | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 000000896491 | 01 | IN | BCBS | OTHER | 201243860 | 05 | IN |   | MEDICAID | 0939640 | 05 | OH |   | MEDICAID |