Healthcare Provider Details

I. General information

NPI: 1801848056
Provider Name (Legal Business Name): TAJVAR H GOUDARZI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6271 SAINT AUGUSTINE RD UFJP SAN JOSE PEDS AND ADOLESCENT CENTER
JACKSONVILLE FL
32217-2523
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0460
  • Fax: 904-633-0461
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME29654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: