Healthcare Provider Details

I. General information

NPI: 1255644118
Provider Name (Legal Business Name): MOSTAFA S ASSADALLA SHERAZY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 NE 191ST ST
AVENTURA FL
33180-3123
US

IV. Provider business mailing address

2999 NE 191ST ST
AVENTURA FL
33180-3123
US

V. Phone/Fax

Practice location:
  • Phone: 786-981-0640
  • Fax: 305-677-8067
Mailing address:
  • Phone: 786-981-0640
  • Fax: 305-677-8067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberIMLC.MD.61164093
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMT196759
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: