Healthcare Provider Details

I. General information

NPI: 1699775866
Provider Name (Legal Business Name): NOUSHIN IZADIFAR HART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NOUSHIN I HART MD

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 ENTERPRISE RD SUITE 100
ORANGE CITY FL
32763-8316
US

IV. Provider business mailing address

2776 ENTERPRISE RD SUITE 100
ORANGE CITY FL
32763-8316
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-1223
  • Fax: 386-774-1507
Mailing address:
  • Phone: 386-774-1223
  • Fax: 386-774-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberL5385
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036101984
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0101248816
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME112142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: