Provider Demographics
NPI:1841907797
Name:DAVOODI, IDA
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:DAVOODI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6982 LAKE NONA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7769
Mailing Address - Country:US
Mailing Address - Phone:916-990-3715
Mailing Address - Fax:
Practice Address - Street 1:6982 LAKE NONA BLVD APT 308
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7897
Practice Address - Country:US
Practice Address - Phone:916-990-3715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH84239183500000X
FLPS64724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist