Healthcare Provider Details

I. General information

NPI: 1538393715
Provider Name (Legal Business Name): MOHAMMAD (MICHAEL) REZA MASSOOMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD BOX 100277
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100277
GAINESVILLE FL
32610-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-9089
  • Fax:
Mailing address:
  • Phone: 352-273-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME128196
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME128196
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: