Basic Information
| Provider Information | |||||||||
| NPI: | 1720282106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAJ | ||||||||
| FirstName: | MOHAMMAD | ||||||||
| MiddleName: | FAROOQ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7751 BAYMEADOWS RD E STE H | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044256963 | ||||||||
| FaxNumber: | 9046740155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 103070 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME103074 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04615 | 01 | FL | BCBS | OTHER | 000778200 | 05 | FL | MEDICAID | BM181U | 01 | FL | MEDICARE | OTHER |