Provider Demographics
NPI:1730100587
Name:FAROOQUE, MOHAMMAD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:FAROOQUE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:SUITE #1106
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-379-5928
Mailing Address - Fax:904-379-5967
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:SUITE #1106
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-379-5928
Practice Address - Fax:904-379-5967
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005013889390200000X
FLME1005502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA565587892AMedicaid
FL1455POtherBCBS
FL0011903-00Medicaid
FLP00800889Medicare PIN
FL0011903-00Medicaid
GA565587892AMedicaid
FLCA696YMedicare PIN