Healthcare Provider Details

I. General information

NPI: 1013116052
Provider Name (Legal Business Name): MONINA ILANO GEDA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 BEACH BLVD STE 102
JACKSONVILLE FL
32250-2643
US

IV. Provider business mailing address

1909 BEACH BLVD SUITE 102
JACKSONVILLE FL
32250-2643
US

V. Phone/Fax

Practice location:
  • Phone: 904-246-2752
  • Fax: 904-246-2758
Mailing address:
  • Phone: 904-246-2752
  • Fax: 904-246-2758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS12954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: