Provider Demographics
NPI:1770522112
Name:HOOSIEN, EBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:
Last Name:HOOSIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13005 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 211,
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9272
Mailing Address - Country:US
Mailing Address - Phone:561-422-0082
Mailing Address - Fax:561-422-0083
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:SUITE 211, MEDICAL MALL 2
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-422-0082
Practice Address - Fax:561-422-0083
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269666500Medicaid
FL269666500Medicaid
FLH73198Medicare UPIN
FLU0006C.U0006UMedicare PIN