Provider Demographics
NPI: | 1942313010 |
---|---|
Name: | RASUL, FAIAZ M (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | FAIAZ |
Middle Name: | M |
Last Name: | RASUL |
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: | PO BOX 549 |
Mailing Address - Street 2: | |
Mailing Address - City: | SHARPES |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32959-0549 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 321-639-4243 |
Mailing Address - Fax: | 321-639-4266 |
Practice Address - Street 1: | 990 PALM ST |
Practice Address - Street 2: | |
Practice Address - City: | COCOA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32927-5145 |
Practice Address - Country: | US |
Practice Address - Phone: | 321-639-4243 |
Practice Address - Fax: | 321-639-4266 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-08-15 |
Last Update Date: | 2011-11-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME72416 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 59-3578159 | Other | TAX # |
FL | 32700B | Other | MEDICARE GROUP # |
FL | 251377300 | Medicaid | |
FL | 32700B | Other | MEDICARE GROUP # |
FL | G43191 | Medicare UPIN | |
FL | E8218 | Medicare PIN | |
FL | E8218 | Medicare ID - Type Unspecified | MEDICARE ID |