Healthcare Provider Details

I. General information

NPI: 1124667217
Provider Name (Legal Business Name): MOHAMMAD ALI FAGHIHI M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 SW 152ND ST STE 209
PALMETTO BAY FL
33157-1942
US

IV. Provider business mailing address

9000 SW 152ND ST STE 209
PALMETTO BAY FL
33157-1942
US

V. Phone/Fax

Practice location:
  • Phone: 786-250-3419
  • Fax: 786-250-3074
Mailing address:
  • Phone: 786-250-3419
  • Fax: 786-250-3074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0205X
TaxonomyPh.D. Medical Genetics Physician
License NumberDI51888
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberDI51888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: