Provider Demographics
NPI:1952924458
Name:FOROUZANDEH, MAHTAB (MD, MPH)
Entity type:Individual
Prefix:
First Name:MAHTAB
Middle Name:
Last Name:FOROUZANDEH
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 PONCE DE LEON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1871
Mailing Address - Country:US
Mailing Address - Phone:502-759-7691
Mailing Address - Fax:
Practice Address - Street 1:4425 PONCE DE LEON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1871
Practice Address - Country:US
Practice Address - Phone:502-759-7691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME169365207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program