Healthcare Provider Details

I. General information

NPI: 1912108721
Provider Name (Legal Business Name): NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 EAGLE HARBOR PARKWAY SUITE 5
FLEMING ISLANG FL
32003-4827
US

IV. Provider business mailing address

1635 EAGLE HARBOR PARKWAY SUITE 5
FLEMING ISLANG FL
32003-4827
US

V. Phone/Fax

Practice location:
  • Phone: 904-384-2240
  • Fax: 904-384-6055
Mailing address:
  • Phone: 904-384-2240
  • Fax: 904-384-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number5497720001
License Number StateFL

VIII. Authorized Official

Name: MRS. DENA CLAY
Title or Position: OFFICE MGR
Credential:
Phone: 904-384-2240