Provider Demographics
NPI:1215911433
Name:NIAZI, MUHAMMED WASIM (MD)
Entity type:Individual
Prefix:
First Name:MUHAMMED
Middle Name:WASIM
Last Name:NIAZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WASIM
Other - Middle Name:
Other - Last Name:NIAZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1910 ROCKLEDGE BLVD
Mailing Address - Street 2:UNT 101
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-636-8366
Mailing Address - Fax:321-636-3985
Practice Address - Street 1:1910 ROCKLEDGE BLVD
Practice Address - Street 2:UNIT 101
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-636-8366
Practice Address - Fax:321-636-3985
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME587322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0500148OtherUNITED
FL4657556OtherAETNA
FL26705OtherBC BS
FL45249OtherBC BS GRP
FL5395693OtherAETNA GRP
FLK1528Medicare ID - Type UnspecifiedGROUP
FL26705OtherBC BS
FL26705YMedicare ID - Type Unspecified