MEDICARE: DR. HAZEM MAHMOUD SAMY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	ME105047	FL
2	207WX0009X	Glaucoma Specialist (Ophthalmology) Physician	ME105047	FL
3	174400000X	Specialist	MD426523	PA
4	207WX0109X	Neuro-ophthalmology Physician	ME105047	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376518399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAZEM MAHMOUD SAMY MD

Provider Business Mailing Address
First Line	:	13241 BARTRAM PARK BLVD UNIT 1505
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5231
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13241 BARTRAM PARK BLVD UNIT 1505
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5231
Country	:	US
Telephone Number	:	904-374-6899
Fax Number	:	904-503-0039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	04/19/2019

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