Provider Demographics
NPI:1447578372
Name:PHILLIPS, MARYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:PHILLIPS
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 1:2905 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FERN PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32730-2009
Mailing Address - Country:US
Mailing Address - Phone:407-900-0613
Mailing Address - Fax:407-393-5504
Practice Address - Street 1:601 E ALTAMONTE DR STE 120
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4802
Practice Address - Country:US
Practice Address - Phone:407-900-0613
Practice Address - Fax:407-393-5504
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2021-04-13
Deactivation Date:2021-03-25
Deactivation Code:
Reactivation Date:2021-04-13
Provider Licenses
StateLicense IDTaxonomies
FLME113946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine