Healthcare Provider Details

I. General information

NPI: 1851684542
Provider Name (Legal Business Name): SINA OGHOLIKHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

10140 CENTURION PKWY N PROVIDER ENROLLMENT DEPARTMENT
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-697-3927
Mailing address:
  • Phone: 904-697-4127
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15898
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberME129261
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: