Healthcare Provider Details

I. General information

NPI: 1477525673
Provider Name (Legal Business Name): PAUL T FASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 NE 191ST ST SUITE 230
AVENTURA FL
33180-3123
US

IV. Provider business mailing address

PO BOX 729
HALLANDALE FL
33008-0729
US

V. Phone/Fax

Practice location:
  • Phone: 305-933-9953
  • Fax:
Mailing address:
  • Phone: 305-503-6320
  • Fax: 305-503-6329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberME15036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: