Provider Demographics
NPI:1821012121
Name:EJAZ, MARIAM FEROZA (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:FEROZA
Last Name:EJAZ
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 1:4033 TAMPA RD
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3224
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-436-5378
Practice Address - Street 1:1812 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5362
Practice Address - Country:US
Practice Address - Phone:813-731-0944
Practice Address - Fax:727-372-3301
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240023208000000X
FLME134156208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics