Basic Information
| Provider Information | |||||||||
| NPI: | 1558504423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGHAEBRAHIM | ||||||||
| FirstName: | AMIN | ||||||||
| MiddleName: | NIMA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 PRUDENTIAL DR | ||||||||
| Address2: | TOWER B, 11TH FLOOR | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043886518 | ||||||||
| FaxNumber: | 9043841005 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043886518 | ||||||||
| FaxNumber: | 9043841005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD448012 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | MD448012 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | ME127798 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P01662142 | 01 | FL | RR MEDICARE | OTHER | 017332100 | 05 | FL | MEDICAID |