MEDICARE: DR. TAJVAR H GOUDARZI 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	208000000X	Pediatrics Physician	ME29654	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

General Provider Information

NPI Number	:	1801848056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAJVAR H GOUDARZI MD

Provider Business Mailing Address
First Line	:	PO BOX 44008
Second Line	:	UFJP PROVIDER ENROLLMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6271 SAINT AUGUSTINE RD
Second Line	:	UFJP SAN JOSE PEDS AND ADOLESCENT CENTER
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2523
Country	:	US
Telephone Number	:	904-633-0460
Fax Number	:	904-633-0461

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	10/26/2009

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