Provider Demographics
NPI:1457370306
Name:NABIZADEH, KASRA A (MD)
Entity Type:Individual
Prefix:
First Name:KASRA
Middle Name:A
Last Name:NABIZADEH
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 1:6484 FORT CAROLINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2042
Mailing Address - Country:US
Mailing Address - Phone:904-744-7300
Mailing Address - Fax:904-722-4271
Practice Address - Street 1:6484 FORT CAROLINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2042
Practice Address - Country:US
Practice Address - Phone:904-744-7300
Practice Address - Fax:904-722-4271
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51611207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049222100Medicaid
FLD21228Medicare UPIN
FL07479AMedicare ID - Type Unspecified