Healthcare Provider Details

I. General information

NPI: 1043209455
Provider Name (Legal Business Name): FIRST COAST RETINA CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8833 PERIMETER PARK BLVD SUITE 203
JACKSONVILLE FL
32216-1109
US

IV. Provider business mailing address

8833 PERIMETER PARK BLVD SUITE 203
JACKSONVILLE FL
32216-1109
US

V. Phone/Fax

Practice location:
  • Phone: 904-997-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH RAPPAPORT
Title or Position: CEO
Credential:
Phone: 904-997-1100