Healthcare Provider Details

I. General information

NPI: 1710499314
Provider Name (Legal Business Name): FAKHREDDIN ROSTAMI FARD ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE STE 700
ORLANDO FL
32804
US

IV. Provider business mailing address

2415 N ORANGE AVE STE 700
ORLANDO FL
32804-5521
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2474
  • Fax:
Mailing address:
  • Phone: 407-303-2474
  • Fax: 407-303-0680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9314282
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: