Healthcare Provider Details

I. General information

NPI: 1366271736
Provider Name (Legal Business Name): IBRAHIM QOZAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2377
  • Fax:
Mailing address:
  • Phone: 904-953-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberTRN39552
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: