Healthcare Provider Details

I. General information

NPI: 1952826075
Provider Name (Legal Business Name): BRUNO DE SOUZA RIBEIRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653-1 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

4555 EMERSON ST STE 300
JACKSONVILLE FL
32207-4958
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-8846
  • Fax:
Mailing address:
  • Phone: 904-633-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number1792
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: