=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861606717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMEDTAKI ABDULAZIZ TEJANI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 07/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 N ORANGE AVE STE 689
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-4648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-2024
-----------------------------------------------------
Fax | 407-303-2038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 N ORANGE AVE STE 689
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-4648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-2024
-----------------------------------------------------
Fax | 407-303-2038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | PENDING
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 003764
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | ME139844
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------