Provider Demographics
NPI:1568452126
Name:YAVARI, MORTEZA GHOLI (MD)
Entity Type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:GHOLI
Last Name:YAVARI
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 1:3550 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4246
Mailing Address - Country:US
Mailing Address - Phone:904-730-2553
Mailing Address - Fax:904-730-2554
Practice Address - Street 1:3550 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4246
Practice Address - Country:US
Practice Address - Phone:904-730-2553
Practice Address - Fax:904-730-2554
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034227174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD85122Medicare UPIN
FL15535Medicare ID - Type Unspecified