Provider Demographics
NPI:1306872767
Name:CENTRAL FLORIDA BREAST CENTER, PA
Entity type:Organization
Organization Name:CENTRAL FLORIDA BREAST CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AZIZ
Authorized Official - Middle Name:SHAHBUDDIN
Authorized Official - Last Name:JASANI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:407-740-5127
Mailing Address - Street 1:2200 GLENWOOD DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3315
Mailing Address - Country:US
Mailing Address - Phone:407-740-5127
Mailing Address - Fax:407-740-0827
Practice Address - Street 1:2200 GLENWOOD DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3315
Practice Address - Country:US
Practice Address - Phone:407-740-5127
Practice Address - Fax:407-740-0827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006978208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5339099OtherAETNA ID #
FL9587978OtherGHI ID #
FL57169OtherBLUE CROSS BLUE SHIELD ID
FL1700176OtherUNITED HEALTHCARE ID
FL9587978OtherGHI ID #
FL=========OtherCIGNA