Provider Demographics
NPI:1255893483
Name:FARZAM, KHASHAYAR (DO)
Entity type:Individual
Prefix:
First Name:KHASHAYAR
Middle Name:
Last Name:FARZAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242
Mailing Address - Country:US
Mailing Address - Phone:319-384-7222
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-384-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2020-03-09
Deactivation Date:2019-11-07
Deactivation Code:
Reactivation Date:2019-11-26
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAR-11496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0123917Medicaid
IAR-11496OtherBOARD OF MEDICINE