Provider Demographics
NPI:1972906261
Name:DR. FERESHTEH NOURAFSHAR M.D.
Entity Type:Organization
Organization Name:DR. FERESHTEH NOURAFSHAR M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FERESHTEH
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURAFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-949-9992
Mailing Address - Street 1:9200 BONITA BEACH RD SE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4280
Mailing Address - Country:US
Mailing Address - Phone:239-949-9992
Mailing Address - Fax:239-949-9006
Practice Address - Street 1:4575 VIA ROYALE
Practice Address - Street 2:SUITE 216
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1043
Practice Address - Country:US
Practice Address - Phone:239-277-9009
Practice Address - Fax:239-277-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76450208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260538400Medicaid
FL260538400Medicaid