Provider Demographics
NPI:1073546701
Name:VIERA FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:VIERA FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSTAFAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-242-7005
Mailing Address - Street 1:8095 SPYGLASS HILL RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8290
Mailing Address - Country:US
Mailing Address - Phone:321-242-7005
Mailing Address - Fax:321-242-7009
Practice Address - Street 1:8095 SPYGLASS HILL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8290
Practice Address - Country:US
Practice Address - Phone:321-242-7005
Practice Address - Fax:321-242-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN