Provider Demographics
NPI:1942308077
Name:GHAZIZADEH, FARIBA (MD)
Entity Type:Individual
Prefix:
First Name:FARIBA
Middle Name:
Last Name:GHAZIZADEH
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:6635 HILLWAY CIR STE 400
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-8757
Practice Address - Country:US
Practice Address - Phone:239-455-9550
Practice Address - Fax:239-455-8980
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F07613Medicare UPIN
FL18612Medicare ID - Type Unspecified