Healthcare Provider Details

I. General information

NPI: 1467895474
Provider Name (Legal Business Name): SHALIZ POURKAVIANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 JACK MARTIN BLVD
BRICK NJ
08724-7732
US

IV. Provider business mailing address

10259 TROUT RD
ORLANDO FL
32836-6544
US

V. Phone/Fax

Practice location:
  • Phone: 407-491-8708
  • Fax:
Mailing address:
  • Phone: 407-491-8708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA155765
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number285686
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME147211
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA10989300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: