Healthcare Provider Details

I. General information

NPI: 1154506376
Provider Name (Legal Business Name): KENNETH JOSEPH EADDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 SAN JOSE PL STE 35
JACKSONVILLE FL
32257-8861
US

IV. Provider business mailing address

3750 SAN JOSE PL STE 35
JACKSONVILLE FL
32257-8861
US

V. Phone/Fax

Practice location:
  • Phone: 904-902-4126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME107723
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME107723
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: