MEDICARE: DR. REZA M. TABA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	ME0047087	FL

General Provider Information

NPI Number	:	1154314128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REZA M. TABA M.D.

Provider Business Mailing Address
First Line	:	3599 UNIVERSITY BLVD S
Second Line	:	SUITE 1201
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4252
Country	:	US
Telephone Number	:	904-399-4185
Fax Number	:	904-396-2628

Provider Business Practice Location Address
First Line	:	3599 UNIVERSITY BLVD S
Second Line	:	SUITE 1201
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4252
Country	:	US
Telephone Number	:	904-399-4185
Fax Number	:	904-396-2628

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	01/10/2017

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