1104121870 NPI number — NOOSHIN ZOLFAGHARI DPM

Table of content: NOOSHIN ZOLFAGHARI DPM (NPI 1104121870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104121870 NPI number — NOOSHIN ZOLFAGHARI DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZOLFAGHARI
Provider First Name:
NOOSHIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104121870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14730 SW 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33027-6107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-899-0520
Provider Business Mailing Address Fax Number:
954-437-3468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2699 STIRLING RD
Provider Second Line Business Practice Location Address:
SUITE A301
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33312-6517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-278-3890
Provider Business Practice Location Address Fax Number:
954-251-1470
Provider Enumeration Date:
01/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  3442 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004505600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6504N . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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