Healthcare Provider Details

I. General information

NPI: 1134757362
Provider Name (Legal Business Name): NOUSHAD MAMUN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13564 VILLAGE PARK DR UNIT 150
ORLANDO FL
32837-7765
US

IV. Provider business mailing address

13564 VILLAGE PARK DR UNIT 150
ORLANDO FL
32837-7765
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-5851
  • Fax: 407-599-1691
Mailing address:
  • Phone: 321-843-5851
  • Fax: 407-599-1691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS22946
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: