Healthcare Provider Details

I. General information

NPI: 1053432252
Provider Name (Legal Business Name): FIRST COAST PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 NECTARINE ST
FERNANDINA BEACH FL
32034-3027
US

IV. Provider business mailing address

1463 NECTARINE ST
FERNANDINA BEACH FL
32034-3027
US

V. Phone/Fax

Practice location:
  • Phone: 904-491-0177
  • Fax: 904-491-3173
Mailing address:
  • Phone: 904-491-0177
  • Fax: 904-491-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CARMITA Z. MARRERO
Title or Position: PARTNER
Credential: MD
Phone: 904-491-0177