Basic Information
| Provider Information | |||||||||
| NPI: | 1578563565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEZFULIAN | ||||||||
| FirstName: | CAMERON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 NW 12TH AVE, | ||||||||
| Address2: | JMT-EAST 1007 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052434664 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055851111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2005 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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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 | 207RC0200X | 102382 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 2080P0203X | 102382 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | ME102382 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000446000 | 05 | FL | MEDICAID |