Provider Demographics
NPI:1013427954
Name:KAZVINOVA, FARIDA
Entity Type:Individual
Prefix:
First Name:FARIDA
Middle Name:
Last Name:KAZVINOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-1107
Mailing Address - Country:US
Mailing Address - Phone:386-496-6000
Mailing Address - Fax:
Practice Address - Street 1:7765 S COUNTY ROAD 231
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-5721
Practice Address - Country:US
Practice Address - Phone:386-496-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121109208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice