Provider Demographics
NPI:1710045539
Name:FARIBORZIAN, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:FARIBORZIAN
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 1:1753 KINGSLEY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4411
Mailing Address - Country:US
Mailing Address - Phone:904-278-5644
Mailing Address - Fax:904-278-5659
Practice Address - Street 1:3292 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-4357
Practice Address - Country:US
Practice Address - Phone:904-291-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 904062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270881700Medicaid