Healthcare Provider Details

I. General information

NPI: 1497312441
Provider Name (Legal Business Name): VIKISHA HAZARIWALA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CONCOURSE PKWY S STE 200
MAITLAND FL
32751-6114
US

IV. Provider business mailing address

790 CONCOURSE PKWY S STE 200
MAITLAND FL
32751-6114
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-6411
  • Fax:
Mailing address:
  • Phone: 407-767-6411
  • Fax: 407-767-8160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberOS20971
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License NumberOS20971
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: