Healthcare Provider Details

I. General information

NPI: 1013221282
Provider Name (Legal Business Name): ANDRE D.C.P. MACEDO DIAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANDRE MACEDO DIAS M.D.

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11236 BAPTIST HEALTH DR STE 310
JACKSONVILLE FL
32218
US

IV. Provider business mailing address

PO BOX 43667
JACKSONVILLE FL
32203-3667
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-9309
  • Fax: 904-764-0086
Mailing address:
  • Phone: 904-720-0599
  • Fax: 904-376-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD454365
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052065
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME136812
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME136812
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: