1801848056 NPI number — DR. TAJVAR H GOUDARZI MD

Table of content: DR. TAJVAR H GOUDARZI MD (NPI 1801848056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801848056 NPI number — DR. TAJVAR H GOUDARZI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOUDARZI
Provider First Name:
TAJVAR
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1801848056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 44008
Provider Second Line Business Mailing Address:
UFJP PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32231-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6271 SAINT AUGUSTINE RD
Provider Second Line Business Practice Location Address:
UFJP SAN JOSE PEDS AND ADOLESCENT CENTER
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32217-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-633-0460
Provider Business Practice Location Address Fax Number:
904-633-0461
Provider Enumeration Date:
05/16/2006

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: 208000000X , with the licence number:  ME29654 , 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: 036871700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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