Provider Demographics
NPI:1669405080
Name:HAKAM, ARDESHIR (MD)
Entity type:Individual
Prefix:
First Name:ARDESHIR
Middle Name:
Last Name:HAKAM
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 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:5426 BEAUMONT CENTER BLVD STE 350
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5235
Practice Address - Country:US
Practice Address - Phone:813-286-0033
Practice Address - Fax:813-282-1806
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72846207ZP0101X, 207ZP0101X
FLME72486207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46656OtherBLUE CROSS BLUE SHIELD
FL256442400Medicaid
FL259947OtherAVMED
FL46656YMedicare PIN
FL46656VMedicare PIN
FL259947OtherAVMED
FL220026275Medicare PIN