Provider Demographics
NPI:1417918988
Name:MUFTAH, AZZAM (MD)
Entity Type:Individual
Prefix:DR
First Name:AZZAM
Middle Name:
Last Name:MUFTAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5305
Mailing Address - Fax:352-616-0926
Practice Address - Street 1:15205 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6072
Practice Address - Country:US
Practice Address - Phone:352-597-7744
Practice Address - Fax:352-597-7797
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68485207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16328OtherWELLCARE
FL219941OtherAVMED
FL28978OtherBLUE CROSS BLUE SHIELD
FL6013192OtherGHI
FL100014202OtherMEDICARE RAILROAD
FL250149000Medicaid
FL5825117OtherAETNA
FL593570847OtherPROVIDER ID
FL16328OtherWELLCARE
FL250149000Medicaid
FL28978XMedicare PIN