Healthcare Provider Details

I. General information

NPI: 1821012121
Provider Name (Legal Business Name): MARIAM FEROZA EJAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 HEALTH CARE DR
TRINITY FL
34655-5362
US

IV. Provider business mailing address

4033 TAMPA RD
OLDSMAR FL
34677-3224
US

V. Phone/Fax

Practice location:
  • Phone: 813-731-0944
  • Fax: 727-372-3301
Mailing address:
  • Phone: 813-854-2003
  • Fax: 813-436-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number240023
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME134156
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier023254100
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: