Healthcare Provider Details

I. General information

NPI: 1578563565
Provider Name (Legal Business Name): CAMERON DEZFULIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2005
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1500 NW 12TH AVE, JMT-EAST 1007
MIAMI FL
33136-1028
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1111
  • Fax:
Mailing address:
  • Phone: 305-243-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number102382
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number102382
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME102382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: