Basic Information
| Provider Information | |||||||||
| NPI: | 1346375839 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AZZAM MUFTAH MD PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 CORTEZ BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346134898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525977744 | ||||||||
| FaxNumber: | 3525977797 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900 CORTEZ BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346134898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525977744 | ||||||||
| FaxNumber: | 3525977797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | MUFTAH | ||||||||
| AuthorizedOfficialFirstName: | AZZAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3525977744 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME 68485 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.