=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942381512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEHNAM BIRGANI DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 02/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4602 N FEDERAL HWY
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-491-4888
-----------------------------------------------------
Fax | 954-202-0504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4611 S UNIVERSITY DR
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-491-4888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | OS0007073
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------