Provider Demographics
NPI:1497312441
Name:HAZARIWALA, VIKISHA (DO)
Entity type:Individual
Prefix:
First Name:VIKISHA
Middle Name:
Last Name:HAZARIWALA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 CONCOURSE PKWY S STE 200
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-6114
Mailing Address - Country:US
Mailing Address - Phone:407-767-6411
Mailing Address - Fax:407-767-8160
Practice Address - Street 1:790 CONCOURSE PKWY S STE 200
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-6114
Practice Address - Country:US
Practice Address - Phone:407-767-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20971207W00000X, 207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS44W0OtherBCBS
FL123331500Medicaid