Basic Information
| Provider Information | |||||||||
| NPI: | 1174753933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REZA | ||||||||
| FirstName: | MOHAMMED | ||||||||
| MiddleName: | BIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4440 FRUITVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342321926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413660134 | ||||||||
| FaxNumber: | 9414041760 | ||||||||
| Practice Location | |||||||||
| Address1: | 4615 PHILIPS HWY STE 3 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045080710 | ||||||||
| FaxNumber: | 8552997010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | ME115865 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 14SC6 | 01 | FL | BCBS FL | OTHER | 009510300 | 05 | FL | MEDICAID | HP209X | 01 | FL | MEDICARE | OTHER |