Provider Demographics
NPI:1558504423
Name:AGHAEBRAHIM, AMIN NIMA (MD)
Entity Type:Individual
Prefix:
First Name:AMIN
Middle Name:NIMA
Last Name:AGHAEBRAHIM
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 1:800 PRUDENTIAL DR
Mailing Address - Street 2:TOWER B, 11TH FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8202
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-388-6518
Practice Address - Fax:904-384-1005
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4480122084N0400X, 2084V0102X
FLME1277982084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01662142OtherRR MEDICARE
FL017332100Medicaid
FL017332100Medicaid