1245347004 NPI number — DR. PABLO MARTIN PELLA MD

Table of content: DR. PABLO MARTIN PELLA MD (NPI 1245347004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245347004 NPI number — DR. PABLO MARTIN PELLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLA
Provider First Name:
PABLO
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245347004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8773 PERIMETER PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-1165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-493-3390
Provider Business Mailing Address Fax Number:
904-493-3395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6817 SOUTHPOINT PKWY STE 801
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-6292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-646-3420
Provider Business Practice Location Address Fax Number:
904-646-3017
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  ME64398 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 250465100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K2410 . This is a "MEDICARE - GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 219953 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 25066 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0111508-00 . This is a "MEDICAID - GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 74509 . This is a "FLORIDA BLUE - GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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