1912108721 NPI number — NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA

Table of content: (NPI 1912108721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912108721 NPI number — NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1912108721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1635 EAGLE HARBOR PARKWAY
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
FLEMING ISLANG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-4827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-384-2240
Provider Business Mailing Address Fax Number:
904-384-6055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1635 EAGLE HARBOR PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
FLEMING ISLANG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-4827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-384-2240
Provider Business Practice Location Address Fax Number:
904-384-6055
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLAY
Authorized Official First Name:
DENA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MGR
Authorized Official Telephone Number:
904-384-2240

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , with the licence number: 5497720001 , 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: 374606200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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