Basic Information
| Provider Information | |||||||||
| NPI: | 1619169356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABATABAI | ||||||||
| FirstName: | ALI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4413 TOWN CENTER PKWY | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322468568 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4413 TOWN CENTER PKWY | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322468568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9049989871 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 08/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC 4245 | FL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.