Provider Demographics
NPI:1881753986
Name:TAMBOLI, KAIZAD P (MD)
Entity type:Individual
Prefix:
First Name:KAIZAD
Middle Name:P
Last Name:TAMBOLI
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 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:305-393-5989
Practice Address - Street 1:2805 54TH AVE N STE 500
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714-2414
Practice Address - Country:US
Practice Address - Phone:305-628-6117
Practice Address - Fax:305-393-5989
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12792207R00000X
FLME91603207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121210Medicaid
MS00121210Medicaid
MSE18838Medicare UPIN
MS110001562Medicare ID - Type Unspecified