Healthcare Provider Details

I. General information

NPI: 1205589306
Provider Name (Legal Business Name): GHAZALEH EBRAHIMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax: 305-284-7755
Mailing address:
  • Phone: 305-284-7500
  • Fax: 305-284-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberTRN40022
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: