Provider Demographics
NPI:1548312051
Name:VISRAM, NIZARALI (MD)
Entity type:Individual
Prefix:DR
First Name:NIZARALI
Middle Name:
Last Name:VISRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12007 WANDSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2614
Mailing Address - Country:US
Mailing Address - Phone:631-807-8589
Mailing Address - Fax:
Practice Address - Street 1:12007 WANDSWORTH DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2614
Practice Address - Country:US
Practice Address - Phone:631-807-8589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21222012081S0010X
FLME86971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI00512Medicare UPIN
NY8P3492Medicare ID - Type Unspecified