Basic Information
| Provider Information | |||||||||
| NPI: | 1497850556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARZAM | ||||||||
| FirstName: | FARJAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12959 PALMS WEST DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334704937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617538888 | ||||||||
| FaxNumber: | 5617955004 | ||||||||
| Practice Location | |||||||||
| Address1: | 12959 PALMS WEST DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334704937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617538888 | ||||||||
| FaxNumber: | 5617955004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | ME116217 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 64096589 | 05 | KY | MEDICAID | 009333600 | 05 | FL | MEDICAID |