Provider Demographics
NPI:1477556272
Name:MADANI, BEHROUZ (MD)
Entity Type:Individual
Prefix:DR
First Name:BEHROUZ
Middle Name:
Last Name:MADANI
Suffix:
Gender:M
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:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33526-1177
Mailing Address - Country:US
Mailing Address - Phone:352-521-1569
Mailing Address - Fax:352-521-1579
Practice Address - Street 1:13540 17TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5244
Practice Address - Country:US
Practice Address - Phone:352-567-1411
Practice Address - Fax:352-567-6391
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279121800Medicaid
FL51076OtherBCBS
FLD55955Medicare UPIN
FL51076WMedicare PIN