Provider Demographics
NPI:1396903605
Name:SAMALIAZAD, ESMAEEL (DC)
Entity type:Individual
Prefix:DR
First Name:ESMAEEL
Middle Name:
Last Name:SAMALIAZAD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1302
Mailing Address - Country:US
Mailing Address - Phone:239-277-9552
Mailing Address - Fax:239-277-7366
Practice Address - Street 1:1953 COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1302
Practice Address - Country:US
Practice Address - Phone:239-277-9552
Practice Address - Fax:239-277-7366
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8642111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381698200Medicaid
FL381698200Medicaid
FLU96679Medicare UPIN