Healthcare Provider Details

I. General information

NPI: 1720348592
Provider Name (Legal Business Name): WIL EDVARD GERMAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10752 DEERWOOD PARK BLVD SOUTH WATERVIEW II SUITE 100
JACKSONVILLE FL
32256-4849
US

IV. Provider business mailing address

12058 SAN JOSE BLVD
JACKSONVILLE FL
32223-8666
US

V. Phone/Fax

Practice location:
  • Phone: 904-755-1017
  • Fax: 646-774-0386
Mailing address:
  • Phone: 917-703-7002
  • Fax: 646-774-0386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number274054
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME137148
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME137148
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: