Provider Demographics
NPI:1235707167
Name:JIWA, ALY-HUSSAIN
Entity Type:Individual
Prefix:
First Name:ALY-HUSSAIN
Middle Name:
Last Name:JIWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 BAY HARBOR DR APT 104
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3410
Mailing Address - Country:US
Mailing Address - Phone:781-535-3185
Mailing Address - Fax:
Practice Address - Street 1:13620 UNIVERSITY PLAZA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4649
Practice Address - Country:US
Practice Address - Phone:813-462-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist