Basic Information
| Provider Information | |||||||||
| NPI: | 1023035987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMTIAZ | ||||||||
| FirstName: | AZIZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10503 BOCA POINTE DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328365800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079444450 | ||||||||
| FaxNumber: | 4079441858 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074830672 | ||||||||
| FaxNumber: | 4073485882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME94323 | FL | N | Other Service Providers | Specialist | 208000000X | ME94323 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.