Provider Demographics
NPI:1043323694
Name:KHOSRAVI, HORMOZJI (MD, PA)
Entity Type:Individual
Prefix:
First Name:HORMOZJI
Middle Name:
Last Name:KHOSRAVI
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-296-3200
Mailing Address - Fax:904-296-0069
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-296-3200
Practice Address - Fax:904-296-0069
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32812174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037158100Medicaid
FL15470WMedicare PIN
FLD52602Medicare UPIN