Provider Demographics
NPI:1154314128
Name:TABA, REZA M (MD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:M
Last Name:TABA
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 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-399-4185
Mailing Address - Fax:904-396-2628
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 1201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-399-4185
Practice Address - Fax:904-396-2628
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047087174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD85104Medicare UPIN
FL14146Medicare ID - Type UnspecifiedRHEUMATOLOGY