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General NPI Number Information
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NPI Number | 1033430327
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Entity Type | Individual
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Provider Name | MICAH BOAZ EDWIN MD
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Gender | Male
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Dates
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Enumeration Date | 06/21/2010
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Last Update Date | 04/08/2021
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Provider Practice Location Address
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Address Line | 4850 W OAKLAND PARK BLVD STE 224
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City | LAUDERDALE LAKES
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State | FL
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Zip | 33313-7261
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Country | US
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Telephone | 786-214-2001
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4067
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City | FT LAUDERDALE
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State | FL
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Zip | 33338-4067
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Country | US
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Telephone | 526-305-2802
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 261987
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME143503
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 2010-01073
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License Number State | NC
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