Provider Demographics
NPI:1174753933
Name:REZA, MOHAMMED BIN (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:BIN
Last Name:REZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 COPPINGER PL
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2263
Mailing Address - Country:US
Mailing Address - Phone:904-808-3688
Mailing Address - Fax:877-904-5575
Practice Address - Street 1:949 LANE AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4706
Practice Address - Country:US
Practice Address - Phone:888-831-2949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115865207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009510300Medicaid
FL14SC6OtherBCBS FL
FLHP209XOtherMEDICARE