Provider Demographics
NPI:1982890687
Name:SHAHRIAR A NABIZADEH MD PA
Entity Type:Organization
Organization Name:SHAHRIAR A NABIZADEH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRIAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:NABIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-803-7593
Mailing Address - Street 1:PO BOX 16373
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6373
Mailing Address - Country:US
Mailing Address - Phone:904-723-0015
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:801 OAK ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4317
Practice Address - Country:US
Practice Address - Phone:904-803-7593
Practice Address - Fax:904-723-5653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
41489OtherBCBS
FL252411200Medicaid
41489OtherBCBS
FLAE853Medicare PIN