Provider Demographics
NPI:1760576706
Name:TABRIZI, PAYAM (MD)
Entity Type:Individual
Prefix:
First Name:PAYAM
Middle Name:
Last Name:TABRIZI
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:1895 KINGSLEY AVE STE 300
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4453
Practice Address - Country:US
Practice Address - Phone:904-375-8850
Practice Address - Fax:904-276-9235
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133411207XX0801X
CAA76882207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A768820Medicare PIN
CAH54373Medicare UPIN
CA00A768820Medicaid