Provider Demographics
NPI:1316074701
Name:MINOUEI, MOHAMMADREZA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMADREZA
Middle Name:
Last Name:MINOUEI
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 1:303 N. CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-425-2285
Mailing Address - Fax:386-425-7522
Practice Address - Street 1:303 N. CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-226-4542
Practice Address - Fax:386-229-2354
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430780207R00000X
FLME103732208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101855627Medicaid
PA109128S8GMedicare PIN
PA101855627Medicaid
FLK8115Medicare PIN