Provider Demographics
NPI:1881376952
Name:MAHDI, MAHDI A (IDC)
Entity type:Individual
Prefix:
First Name:MAHDI
Middle Name:A
Last Name:MAHDI
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 SPARROW BRANCH CIR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4543
Mailing Address - Country:US
Mailing Address - Phone:619-372-6817
Mailing Address - Fax:
Practice Address - Street 1:337 SPARROW BRANCH CIR
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4543
Practice Address - Country:US
Practice Address - Phone:619-372-6817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman