Healthcare Provider Details

I. General information

NPI: 1053750794
Provider Name (Legal Business Name): KENZO JAMES PAUL KOIKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2013
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE UNIT 534
JACKSONVILLE FL
32256
US

IV. Provider business mailing address

11512 LAKE MEAD AVE UNIT 534
JACKSONVILLE FL
32256-5835
US

V. Phone/Fax

Practice location:
  • Phone: 904-564-2020
  • Fax:
Mailing address:
  • Phone: 904-274-1819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberME135382
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberR2382
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME135382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: