Provider Demographics
NPI:1780846667
Name:GHORSRIZ, ROYA (DO)
Entity Type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:GHORSRIZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4191
Mailing Address - Country:US
Mailing Address - Phone:863-294-0670
Mailing Address - Fax:863-298-3200
Practice Address - Street 1:635 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4191
Practice Address - Country:US
Practice Address - Phone:863-294-0670
Practice Address - Fax:863-298-3200
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10208207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBA526YMedicare UPIN