Provider Demographics
NPI:1962091520
Name:ICMD PA
Entity type:Organization
Organization Name:ICMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIBORZ
Authorized Official - Middle Name:
Authorized Official - Last Name:DELBAKHSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-455-2026
Mailing Address - Street 1:10770 SE 173RD ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-6851
Mailing Address - Country:US
Mailing Address - Phone:352-455-2026
Mailing Address - Fax:352-748-2700
Practice Address - Street 1:10770 SE 173RD ST
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-6851
Practice Address - Country:US
Practice Address - Phone:352-455-2026
Practice Address - Fax:352-748-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty