Provider Demographics
NPI:1962645671
Name:FARIDANI, VINCE (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCE
Middle Name:
Last Name:FARIDANI
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 1:1620 NW 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-2538
Mailing Address - Country:US
Mailing Address - Phone:954-895-5729
Mailing Address - Fax:
Practice Address - Street 1:1620 NW 122ND AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-2538
Practice Address - Country:US
Practice Address - Phone:954-895-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135081207R00000X, 208M00000X
GA70100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLI837OtherMEDICARE - FL
FL102506400Medicaid