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
StateLicense IDTaxonomies
FLME72416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-3578159OtherTAX #
FL32700BOtherMEDICARE GROUP #
FL251377300Medicaid
FL32700BOtherMEDICARE GROUP #
FLG43191Medicare UPIN
FLE8218Medicare PIN
FLE8218Medicare ID - Type UnspecifiedMEDICARE ID