MEDICARE: NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist
2	332BC3200X	Customized Equipment (DME)	5497720001	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912108721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA

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

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

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	MRS. DENA CLAY
Credential	:
Telephone Number	:	904-384-2240

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	10/18/2012

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