Healthcare Provider Details

I. General information

NPI: 1033092366
Provider Name (Legal Business Name): SOUTH ATLANTIC RETINA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3627 UNIVERSITY BLVD S STE 605
JACKSONVILLE FL
32216-7401
US

IV. Provider business mailing address

4719 VALHALLA CT
COLUMBIA MO
65203-4212
US

V. Phone/Fax

Practice location:
  • Phone: 904-658-0176
  • Fax:
Mailing address:
  • Phone: 904-658-0176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AHMED M ELKEEB
Title or Position: OWNER
Credential: MD, MBA
Phone: 904-658-0176