Healthcare Provider Details

I. General information

NPI: 1083290712
Provider Name (Legal Business Name): PAYAM MOHAMMADINEJAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 W 8TH ST
JACKSONVILLE FL
32209
US

IV. Provider business mailing address

UNIVERSITY OF TEXAS MEDICAL BRANCH 301 UNIVERSITY BLVD
GALVESTON TX
77555-0709
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-4225
  • Fax:
Mailing address:
  • Phone: 409-747-2849
  • Fax: 409-772-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberBP10079529
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: