=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023244381
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RIAZ AHMED M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2009
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1536 N JEFFERSON ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32209-6525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-470-5800
-----------------------------------------------------
Fax | 352-384-8014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 HILDEN RD STE 108
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-8401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-834-8042
-----------------------------------------------------
Fax | 904-717-8429
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | P70149
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ACN820
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------