Provider Demographics
NPI:1629077573
Name:HESSAMI, MIRATIQULLAH (MD)
Entity Type:Individual
Prefix:
First Name:MIRATIQULLAH
Middle Name:
Last Name:HESSAMI
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 1:33425 E LAKE JOANNA DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-7249
Mailing Address - Country:US
Mailing Address - Phone:352-223-5244
Mailing Address - Fax:352-735-4262
Practice Address - Street 1:33425 E LAKE JOANNA DR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32736-7249
Practice Address - Country:US
Practice Address - Phone:352-223-5244
Practice Address - Fax:352-735-4262
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 81337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG90215Medicare UPIN
FL51713Medicare ID - Type Unspecified