Healthcare Provider Details

I. General information

NPI: 1780905489
Provider Name (Legal Business Name): AHMAD T A A A DEHRAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
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

337 IVES DAIRY RD APT 5
MIAMI FL
33179-3350
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5215
  • Fax:
Mailing address:
  • Phone: 350-974-5548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number15135
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: