Healthcare Provider Details

I. General information

NPI: 1215070396
Provider Name (Legal Business Name): MERVIN PUNZALAN MANUEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 NECTARINE ST
FERNANDINA BEACH FL
32034-3027
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
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 NumberME123580
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: