Healthcare Provider Details

I. General information

NPI: 1316915663
Provider Name (Legal Business Name): JOSE ALBERTO ETTEDGUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR STE 280
JACKSONVILLE FL
32207-8350
US

IV. Provider business mailing address

PO BOX 40767
JACKSONVILLE FL
32203-0767
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-8550
  • Fax: 904-393-7808
Mailing address:
  • Phone: 904-376-3707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME86378
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME86378
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: