Provider Demographics
NPI:1588205884
Name:MOHAMMAD TAJ LLC
Entity Type:Organization
Organization Name:MOHAMMAD TAJ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-264-6977
Mailing Address - Street 1:1543 KINGSLEY AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4570
Mailing Address - Country:US
Mailing Address - Phone:904-264-6977
Mailing Address - Fax:904-269-0870
Practice Address - Street 1:1543 KINGSLEY AVE STE 14
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4570
Practice Address - Country:US
Practice Address - Phone:904-264-6977
Practice Address - Fax:904-269-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty