Healthcare Provider Details

I. General information

NPI: 1215994942
Provider Name (Legal Business Name): ALI VAZIRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 09/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11375 CORTEZ BLVD
BROOKSVILLE FL
34613-5409
US

IV. Provider business mailing address

11375 CORTEZ BLVD
BROOKSVILLE FL
34613-5409
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-6137
  • Fax:
Mailing address:
  • Phone: 352-597-6137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME131174
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME131174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: