1386801116 NPI number — DR. ABDOLREZA MOHAMMADIAN M.D

Table of content: DR. ABDOLREZA MOHAMMADIAN M.D (NPI 1386801116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386801116 NPI number — DR. ABDOLREZA MOHAMMADIAN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHAMMADIAN
Provider First Name:
ABDOLREZA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1386801116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1536 NORTH JEFFERSON STREET
Provider Second Line Business Mailing Address:
VA OUTPATIENT CLINIC
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-475-5800
Provider Business Mailing Address Fax Number:
904-301-2502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1536 N.JEFFERSON STREET
Provider Second Line Business Practice Location Address:
VA OUTPATIENT CLINIC
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32209-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-475-5800
Provider Business Practice Location Address Fax Number:
904-301-2502
Provider Enumeration Date:
05/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1386801116 . This is a "FAMILY PRACTICE AND GERIATRIC MEDICINE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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