Basic Information
| Provider Information | |||||||||
| NPI: | 1417918988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUFTAH | ||||||||
| FirstName: | AZZAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 PINEHURST DR | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346063833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522775305 | ||||||||
| FaxNumber: | 3526160926 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900 CORTEZ BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346134898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525977744 | ||||||||
| FaxNumber: | 3525977797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME68485 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100014202 | 01 | FL | MEDICARE RAILROAD | OTHER | 219941 | 01 | FL | AVMED | OTHER | 5825117 | 01 | FL | AETNA | OTHER | 28978 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 593570847 | 01 | FL | PROVIDER ID | OTHER | 16328 | 01 | FL | WELLCARE | OTHER | 250149000 | 05 | FL | MEDICAID | 6013192 | 01 | FL | GHI | OTHER |