1114059201 NPI number — REZA AZARI SAMANI, DDS PA

Table of content: (NPI 1114059201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114059201 NPI number — REZA AZARI SAMANI, DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REZA AZARI SAMANI, DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114059201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14453 BEACH BLVD.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-992-8900
Provider Business Mailing Address Fax Number:
904-992-4922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14453 BEACH BLVD.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-992-8900
Provider Business Practice Location Address Fax Number:
904-992-4922
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAMANI
Authorized Official First Name:
REZA
Authorized Official Middle Name:
AZARI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-992-8900

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  12860 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 69855 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 826747 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".




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