Provider Demographics
NPI:1205116399
Name:ROYA GHADIMI, M.D., P.A.
Entity type:Organization
Organization Name:ROYA GHADIMI, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHADIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-593-6120
Mailing Address - Street 1:1415 PANTHER LN
Mailing Address - Street 2:SUITE 322
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-7874
Mailing Address - Country:US
Mailing Address - Phone:239-593-6120
Mailing Address - Fax:
Practice Address - Street 1:1415 PANTHER LN
Practice Address - Street 2:SUITE 322
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-7874
Practice Address - Country:US
Practice Address - Phone:239-593-6120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107176103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG38675Medicare UPIN