Healthcare Provider Details

I. General information

NPI: 1922063924
Provider Name (Legal Business Name): MCIVER UROLOGICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LOMAX ST
JACKSONVILLE FL
32204-4004
US

IV. Provider business mailing address

710 LOMAX ST
JACKSONVILLE FL
32204-4004
US

V. Phone/Fax

Practice location:
  • Phone: 904-355-6583
  • Fax: 904-355-4922
Mailing address:
  • Phone: 904-355-6583
  • Fax: 904-355-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN WHITTAKER
Title or Position: PRESIDENT
Credential: MD
Phone: 904-355-6583