Provider Demographics
NPI:1659374320
Name:KASRAEIAN, AHMAD (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:KASRAEIAN
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 1:6269 BEACH BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2705
Mailing Address - Country:US
Mailing Address - Phone:904-727-7955
Mailing Address - Fax:904-727-7976
Practice Address - Street 1:6269 BEACH BLVD
Practice Address - Street 2:STE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2705
Practice Address - Country:US
Practice Address - Phone:904-727-7955
Practice Address - Fax:904-727-7976
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-08-02
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
FLFLME 0029693208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043722100Medicaid
FLD52480Medicare UPIN
FL14153Medicare PIN