Provider Demographics
NPI:1598737736
Name:MAZAHERI, SHARAREH (MD)
Entity Type:Individual
Prefix:
First Name:SHARAREH
Middle Name:
Last Name:MAZAHERI
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 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3019
Mailing Address - Country:US
Mailing Address - Phone:863-680-7008
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-680-7190
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15004Medicare UPIN
FL48066ZMedicare PIN
FL270343200Medicaid
FL0471260001Medicare NSC