Healthcare Provider Details

I. General information

NPI: 1790697951
Provider Name (Legal Business Name): DR. UNKNOWN SHAMS UD DIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE FL 33136
MIAMI FL
33136-1005
US

IV. Provider business mailing address

11131 SW 143RD CT
MIAMI FL
33186-7052
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1111
  • Fax:
Mailing address:
  • Phone: 561-647-3272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberTRN46620
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: