Provider Demographics
NPI:1023035987
Name:IMTIAZ, AZIZ (MD)
Entity Type:Individual
Prefix:
First Name:AZIZ
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10503 BOCA POINTE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5800
Mailing Address - Country:US
Mailing Address - Phone:407-944-4450
Mailing Address - Fax:407-944-1858
Practice Address - Street 1:1412 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4051
Practice Address - Country:US
Practice Address - Phone:407-483-0672
Practice Address - Fax:407-348-5882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94323174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH29859Medicare UPIN