Provider Demographics
NPI:1114122660
Name:JALLALI, MASSOOD (DPM)
Entity Type:Individual
Prefix:
First Name:MASSOOD
Middle Name:
Last Name:JALLALI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5842
Mailing Address - Country:US
Mailing Address - Phone:954-274-7454
Mailing Address - Fax:
Practice Address - Street 1:2337 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-5842
Practice Address - Country:US
Practice Address - Phone:954-274-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2747213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65589Medicare ID - Type UnspecifiedFL MEDICARE
FLU74467Medicare UPIN