Provider Demographics
NPI:1306807201
Name:NOWROOZI, MARYAM M (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:M
Last Name:NOWROOZI
Suffix:
Gender:F
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:
Practice Address - Street 1:4106 PORTSMOUTH BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701
Practice Address - Country:US
Practice Address - Phone:757-393-1136
Practice Address - Fax:757-698-2499
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233196207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010221871Medicaid
VA186909OtherANTHEM BCBS
VA009235G68Medicare PIN
VA186909OtherANTHEM BCBS
VA009235G68Medicare ID - Type Unspecified