Provider Demographics
NPI:1528212651
Name:KISSIMMEE PRIMARY CARE/ ANTI-AGING WELLNESS AND WEIGHT LOSS CENTER PA
Entity Type:Organization
Organization Name:KISSIMMEE PRIMARY CARE/ ANTI-AGING WELLNESS AND WEIGHT LOSS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SYED SHAFEEQ
Authorized Official - Middle Name:UR
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-518-7700
Mailing Address - Street 1:1520 N. JOHN YOUNG PARKWAY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-3219
Mailing Address - Country:US
Mailing Address - Phone:407-518-7700
Mailing Address - Fax:407-518-7100
Practice Address - Street 1:1520 N. JOHN YOUNG PARKWAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3219
Practice Address - Country:US
Practice Address - Phone:407-518-7700
Practice Address - Fax:407-518-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86628208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty