Healthcare Provider Details

I. General information

NPI: 1356429625
Provider Name (Legal Business Name): SHAZIA MUKADDAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 COCONUT CREEK PKWY
MARGATE FL
33063-3913
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 954-281-7700
  • Fax: 954-715-7603
Mailing address:
  • Phone: 954-281-7700
  • Fax: 954-715-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08136600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME129980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: