Healthcare Provider Details

I. General information

NPI: 1174924963
Provider Name (Legal Business Name): IVAN ISLAMAJ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 NW 72ND AVE STE PH-1
MIAMI FL
33126-1936
US

IV. Provider business mailing address

1150 NW 72ND AVE STE PH-1
MIAMI FL
33126-1936
US

V. Phone/Fax

Practice location:
  • Phone: 216-502-6577
  • Fax: 305-701-9902
Mailing address:
  • Phone: 216-502-6577
  • Fax: 305-701-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9107915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: