Provider Demographics
NPI:1164955407
Name:MORIDI, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MORIDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 KINGSLEY AVE STE 390
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4484
Mailing Address - Country:US
Mailing Address - Phone:904-639-2260
Mailing Address - Fax:
Practice Address - Street 1:9835 N LAKE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-6210
Practice Address - Country:US
Practice Address - Phone:737-229-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4559207V00000X
WAT4559207V00000X
FLME161977207V00000X
DCMD210001941207V00000X
PAMD489965C207VX0000X
WI13389207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty