Provider Demographics
NPI:1265492565
Name:FARAHMAND, AUDREY ESHRAT (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:ESHRAT
Last Name:FARAHMAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 COURT OF PALMS
Mailing Address - Street 2:UNIT #605
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-6545
Mailing Address - Country:US
Mailing Address - Phone:239-332-2388
Mailing Address - Fax:239-332-2382
Practice Address - Street 1:14090 METROPOLIS AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-332-2388
Practice Address - Fax:239-332-2382
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89962208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20-2539348OtherTAX ID
FL48097OtherBLUE CROSS BLUE SHIELD
FLH59792Medicare UPIN
FL48097OtherBLUE CROSS BLUE SHIELD
FLU2734YMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER