Provider Demographics
NPI:1457560906
Name:TAVANAIEPOUR, DARYOUSH (MD)
Entity type:Individual
Prefix:
First Name:DARYOUSH
Middle Name:
Last Name:TAVANAIEPOUR
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 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:580 W 8TH ST
Practice Address - Street 2:TOWER1 8TH FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6533
Practice Address - Country:US
Practice Address - Phone:904-383-1022
Practice Address - Fax:904-244-9430
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247523207T00000X
VA0116016383390200000X
FLME113574207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14KZ4OtherBCBSFL
GA003125606AMedicaid
FL005931400Medicaid
FL14KZ4OtherBCBSFL