Healthcare Provider Details

I. General information

NPI: 1164955407
Provider Name (Legal Business Name): IRENE MORIDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9835 N LAKE CREEK PKWY
AUSTIN TX
78717-6210
US

IV. Provider business mailing address

1825 KINGSLEY AVE STE 390
ORANGE PARK FL
32073-4484
US

V. Phone/Fax

Practice location:
  • Phone: 737-229-2100
  • Fax:
Mailing address:
  • Phone: 904-639-2260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberC1-0028447
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberT4559
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13389
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD210001941
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME161977
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberT4559
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberMD489965C
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: