Healthcare Provider Details

I. General information

NPI: 1073017174
Provider Name (Legal Business Name): NISREEN SHABBIR EZUDDIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 NW 170TH ST
NORTH MIAMI BEACH FL
33169-5521
US

IV. Provider business mailing address

4581 WESTON RD
WESTON FL
33331-3141
US

V. Phone/Fax

Practice location:
  • Phone: 305-651-1100
  • Fax:
Mailing address:
  • Phone: 305-654-5221
  • Fax: 305-654-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2025039391
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0451790
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0451790
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2025039391
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME146753
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: