Healthcare Provider Details

I. General information

NPI: 1760164602
Provider Name (Legal Business Name): MUTAZ SHAHEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WATERMAN WAY
TAVARES FL
32778-5266
US

IV. Provider business mailing address

1169 HOE AVE APT 4C
BRONX NY
10459-4425
US

V. Phone/Fax

Practice location:
  • Phone: 352-742-3578
  • Fax: 352-742-3581
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME178878
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: