Provider Demographics
NPI:1174635148
Name:JACKSONVILLE COSMETIC SURGRY CENTER
Entity Type:Organization
Organization Name:JACKSONVILLE COSMETIC SURGRY CENTER
Other - Org Name:PLASTIC AND COSMETIC SURGERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:A.H.
Authorized Official - Middle Name:
Authorized Official - Last Name:NEZAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-399-5061
Mailing Address - Street 1:820 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 702
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8210
Mailing Address - Country:US
Mailing Address - Phone:904-399-5061
Mailing Address - Fax:904-399-5062
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 702
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-399-5061
Practice Address - Fax:904-399-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL138OtherOFFICE SERGERY REGISTRATI