Provider Demographics
NPI:1891012365
Name:JAX OB-GYN PA
Entity Type:Organization
Organization Name:JAX OB-GYN PA
Other - Org Name:HORMOZ KHOSRAVI, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HORMOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSRAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-737-1920
Mailing Address - Street 1:4123 UNIVERSITY BLVD S.
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216
Mailing Address - Country:US
Mailing Address - Phone:904-737-1920
Mailing Address - Fax:904-737-8932
Practice Address - Street 1:4123 UNIVERSITY BLVD S.
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-737-1920
Practice Address - Fax:904-737-8932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32812207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037158100Medicaid
FL037158100Medicaid