Provider Demographics
NPI:1801848056
Name:GOUDARZI, TAJVAR H (MD)
Entity type:Individual
Prefix:DR
First Name:TAJVAR
Middle Name:H
Last Name:GOUDARZI
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6271 SAINT AUGUSTINE RD
Practice Address - Street 2:UFJP SAN JOSE PEDS AND ADOLESCENT CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2523
Practice Address - Country:US
Practice Address - Phone:904-633-0460
Practice Address - Fax:904-633-0461
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME29654208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036871700Medicaid
FL15464WMedicare PIN
FLD52597Medicare UPIN
FL15464YMedicare ID - Type Unspecified