=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164693537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAAZALI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2008
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14540 CORTEZ BLVD SUITE # 116
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-6056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-797-9677
-----------------------------------------------------
Fax | 352-797-9857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11451 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-7367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-797-9677
-----------------------------------------------------
Fax | 352-600-8913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SYED WAJAHAT ALI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 352-797-9677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME83482
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------