Provider Demographics
NPI:1699775866
Name:HART, NOUSHIN IZADIFAR (MD)
Entity type:Individual
Prefix:
First Name:NOUSHIN
Middle Name:IZADIFAR
Last Name:HART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NOUSHIN
Other - Middle Name:I
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2776 ENTERPRISE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8316
Mailing Address - Country:US
Mailing Address - Phone:386-774-1223
Mailing Address - Fax:386-774-1507
Practice Address - Street 1:2776 ENTERPRISE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8316
Practice Address - Country:US
Practice Address - Phone:386-774-1223
Practice Address - Fax:386-774-1507
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL53852085R0001X
IL0361019842085R0001X
VA01012488162085R0001X
FLME1121422085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B1190OtherMEDICARE PTAN
TX00250TOtherGROUP MEDICARE PIN
TX00251TOtherGROUP MEDICARE PIN
TX00250TOtherGROUP MEDICARE PIN
TX8B1190OtherMEDICARE PTAN
H11518Medicare UPIN
TX8B1190Medicare PIN