Provider Demographics
NPI:1053316190
Name:MOEZI, MEHDI M (MD)
Entity Type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:M
Last Name:MOEZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 AC SKINNER PARKWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:2370 MARKET DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4326
Practice Address - Country:US
Practice Address - Phone:094-264-6201
Practice Address - Fax:904-264-6858
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80061207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107612BMedicaid
FL260425600Medicaid
FL51687OtherBCBS
FL7767303OtherAETNA
FL281224OtherAVMED
FLH29994Medicare UPIN
FL281224OtherAVMED
GA003107612BMedicaid
FL51687VMedicare PIN
FL51687XMedicare PIN