Provider Demographics
NPI:1932380441
Name:TAVAKKOLI, HASSAN (DO)
Entity Type:Individual
Prefix:DR
First Name:HASSAN
Middle Name:
Last Name:TAVAKKOLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 39209
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339
Mailing Address - Country:US
Mailing Address - Phone:954-851-9966
Mailing Address - Fax:954-318-7360
Practice Address - Street 1:8051 W. SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322
Practice Address - Country:US
Practice Address - Phone:954-474-2900
Practice Address - Fax:954-474-2901
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 6626207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0853300OtherAETNA
FL650505235OtherUNITEDHEALTHCARE
FL375397200OtherMEDICAID
FL80799OtherBLUE CROSS BLUE SHIELD
FL235914OtherAVMED
FL375397200Medicaid
F05100Medicare UPIN
FL375397200Medicaid
FLF05100Medicare UPIN
FL80799Medicare PIN