Provider Demographics
NPI:1720282106
Name:TAJ, MOHAMMAD FAROOQ (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:FAROOQ
Last Name:TAJ
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:7751 BAYMEADOWS RD E STE H
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5836
Practice Address - Country:US
Practice Address - Phone:904-425-6963
Practice Address - Fax:904-674-0155
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103070207R00000X
FLME103074207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04615OtherBCBS
FL000778200Medicaid
FLBM181UOtherMEDICARE