Healthcare Provider Details

I. General information

NPI: 1932136025
Provider Name (Legal Business Name): KENNETH M VANOSDOL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 BARRS ST
JACKSONVILLE FL
32204-4704
US

IV. Provider business mailing address

PO BOX 863026
ORLANDO FL
32886-3026
US

V. Phone/Fax

Practice location:
  • Phone: 904-303-8730
  • Fax: 904-346-0113
Mailing address:
  • Phone: 904-346-5426
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA1027204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: