Provider Demographics
NPI:1346771623
Name:AZMATH, MISBAH FATHIMA
Entity Type:Individual
Prefix:DR
First Name:MISBAH
Middle Name:FATHIMA
Last Name:AZMATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W FAIRBANKS AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4777
Mailing Address - Country:US
Mailing Address - Phone:321-841-4371
Mailing Address - Fax:407-936-3866
Practice Address - Street 1:1111 W FAIRBANKS AVE STE 110
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4777
Practice Address - Country:US
Practice Address - Phone:321-841-4371
Practice Address - Fax:407-936-3866
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME165638207RE0101X
CT072504207R00000X, 207RE0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120527100Medicaid