Provider Demographics
NPI:1154940674
Name:KOOCHAKZADEH, SINA
Entity type:Individual
Prefix:
First Name:SINA
Middle Name:
Last Name:KOOCHAKZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100264 1345 CENTER DRVE RM2-M228
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0001
Mailing Address - Country:US
Mailing Address - Phone:352-273-5199
Mailing Address - Fax:352-392-6781
Practice Address - Street 1:1345 CENTER DRVE RM2-M228
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0001
Practice Address - Country:US
Practice Address - Phone:352-273-5199
Practice Address - Fax:352-392-6781
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program