Healthcare Provider Details

I. General information

NPI: 1912161340
Provider Name (Legal Business Name): JOSE RAPHAEL G TAMAYO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 16TH AVE S # 216
JACKSONVILLE BEACH FL
32250-3213
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-7778
  • Fax: 904-390-7389
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 108621
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: