Healthcare Provider Details

I. General information

NPI: 1659812394
Provider Name (Legal Business Name): FIRST COAST CARDIOVASCULAR INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BARTRAM OAKS WALK STE 104
FRUIT COVE FL
32259-3247
US

IV. Provider business mailing address

PO BOX 551308
JACKSONVILLE FL
32255-1308
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-3333
  • Fax: 904-268-5505
Mailing address:
  • Phone: 904-493-3333
  • Fax: 904-493-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. YAZAN KHATIB
Title or Position: PRESIDENT
Credential: MD
Phone: 904-493-3333