Healthcare Provider Details

I. General information

NPI: 1417918988
Provider Name (Legal Business Name): AZZAM MUFTAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15205 CORTEZ BLVD
BROOKSVILLE FL
34613-6072
US

IV. Provider business mailing address

5400 PINEHURST DR
SPRING HILL FL
34606-3833
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-7744
  • Fax: 352-597-7797
Mailing address:
  • Phone: 352-277-5305
  • Fax: 352-616-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME68485
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: