Provider Demographics
NPI:1710473889
Name:EBNESHAHIDI, HAMIDREZA (MD)
Entity Type:Individual
Prefix:DR
First Name:HAMIDREZA
Middle Name:
Last Name:EBNESHAHIDI
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 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:601 E DIXIE AVE STE 102
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5953
Practice Address - Country:US
Practice Address - Phone:352-350-8888
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19992208D00000X
FLACN1122208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFE7692355OtherDEA