Healthcare Provider Details

I. General information

NPI: 1821618141
Provider Name (Legal Business Name): MARIAM VAEZI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 11/01/2025
Certification Date: 11/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 HALPERIN AVE
BRONX NY
10461-2630
US

IV. Provider business mailing address

2626 HALPERIN AVE
BRONX NY
10461-2631
US

V. Phone/Fax

Practice location:
  • Phone: 718-583-7736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number60011312
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60011312
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: