Provider Demographics
NPI:1871883850
Name:FAZA, BRANDON I (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:I
Last Name:FAZA
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16318 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1341
Mailing Address - Country:US
Mailing Address - Phone:813-576-0077
Mailing Address - Fax:
Practice Address - Street 1:16318 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1341
Practice Address - Country:US
Practice Address - Phone:813-576-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1158802083S0010X, 208D00000X, 207P00000X
FLTRN17983390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program