Provider Demographics
NPI:1336138734
Name:SAMIIAN, MOHAMAD REZA (MD PA)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:REZA
Last Name:SAMIIAN
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 1:4221 SOUTHPOINT PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-296-2810
Mailing Address - Fax:904-296-3424
Practice Address - Street 1:4221 SOUTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-296-2810
Practice Address - Fax:904-296-3424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME20018208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15880OtherPROVIDER #
FLD52771Medicare UPIN
FL15880Medicare ID - Type Unspecified