=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073225181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE RIAZ CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2022
-----------------------------------------------------
Last Update Date | 12/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3342 NE 34TH ST
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-6906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-358-2363
-----------------------------------------------------
Fax | 954-306-2232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3342 NE 34TH ST
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-6906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-358-2363
-----------------------------------------------------
Fax | 954-306-2232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | AHMED RIAZ
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 305-495-9560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------