Provider Demographics
NPI:1043006851
Name:ESFAHANI ZADEH, MITRA
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:ESFAHANI ZADEH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 FOGGY BROOK PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5726
Mailing Address - Country:US
Mailing Address - Phone:407-800-2252
Mailing Address - Fax:
Practice Address - Street 1:1005 FOGGY BROOK PL
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5726
Practice Address - Country:US
Practice Address - Phone:407-800-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI45553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist