Healthcare Provider Details

I. General information

NPI: 1174715858
Provider Name (Legal Business Name): ROBERTO FOURZALI SABBAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

PO BOX 166474
MIAMI FL
33116-6474
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-5512
  • Fax: 305-243-4613
Mailing address:
  • Phone: 855-826-6460
  • Fax: 772-621-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME115642
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: