Healthcare Provider Details

I. General information

NPI: 1265492565
Provider Name (Legal Business Name): AUDREY ESHRAT FARAHMAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14090 METROPOLIS AVE SUITE #102
FORT MYERS FL
33912
US

IV. Provider business mailing address

11600 COURT OF PALMS UNIT #605
FORT MYERS FL
33908-6545
US

V. Phone/Fax

Practice location:
  • Phone: 239-332-2388
  • Fax: 239-332-2382
Mailing address:
  • Phone: 239-332-2388
  • Fax: 239-332-2382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME89962
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: