Healthcare Provider Details

I. General information

NPI: 1992065163
Provider Name (Legal Business Name): ELIAS IVAN COUTO BARBOSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 03/20/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PRUDENTIAL DR STE 304
JACKSONVILLE FL
32207-8205
US

IV. Provider business mailing address

655 WEST 8TH ST. ACC BLDG, 4TH FLOOR
JACKSONVILLE FL
32209
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-3860
  • Fax: 904-202-3846
Mailing address:
  • Phone: 904-383-1013
  • Fax: 904-244-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME124789
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number124789
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME124789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: