Provider Demographics
NPI:1205868742
Name:MALTBY, NEDDA SALEHI (MD)
Entity type:Individual
Prefix:
First Name:NEDDA
Middle Name:SALEHI
Last Name:MALTBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NEDDA
Other - Middle Name:
Other - Last Name:MOHAMMAD-POUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT,
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-5985
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3694
Practice Address - Fax:904-697-3792
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228873208000000X
FLME101329208000000X, 208M00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2813661-00Medicaid
GA374090402AMedicaid
FL281366100Medicaid
FLBH468ZMedicare PIN