Provider Demographics
NPI:1619331808
Name:SOUTHERN FLORIDA MEDICAL GROUP
Entity Type:Organization
Organization Name:SOUTHERN FLORIDA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GAMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAZNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-243-5225
Mailing Address - Street 1:3657 MADACA LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2048
Mailing Address - Country:US
Mailing Address - Phone:586-243-5225
Mailing Address - Fax:
Practice Address - Street 1:6399 SW 120TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-4832
Practice Address - Country:US
Practice Address - Phone:305-519-1447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty