Provider Demographics
NPI:1083644421
Name:NOURI, KEYVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEYVAN
Middle Name:
Last Name:NOURI
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 1:1475 NW 12 AVE
Mailing Address - Street 2:BOX 016960
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101
Mailing Address - Country:US
Mailing Address - Phone:305-243-8693
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1475 NW 12 AVE
Practice Address - Street 2:BOX 016960
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33101
Practice Address - Country:US
Practice Address - Phone:305-243-8693
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71012207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2553449-00Medicaid
FL44671Medicare UPIN
FLG63254Medicare UPIN