Provider Demographics
NPI:1366655821
Name:NABAVI, MARYAM D (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:D
Last Name:NABAVI
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 1:13774 PLANTATION RD
Mailing Address - Street 2:STE 105
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4461
Mailing Address - Country:US
Mailing Address - Phone:239-231-1342
Mailing Address - Fax:
Practice Address - Street 1:13774 PLANTATION RD
Practice Address - Street 2:STE 105
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4461
Practice Address - Country:US
Practice Address - Phone:239-231-1342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN404208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice