=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679192322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BURHAN RIAZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2020
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 646 HILLS BLVD
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-364-4453
-----------------------------------------------------
Fax | 213-205-1193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 646 HILLS BLVD
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-443-2938
-----------------------------------------------------
Fax | 213-205-1193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME167030
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 328497
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------