Healthcare Provider Details

I. General information

NPI: 1265968929
Provider Name (Legal Business Name): NORTHEAST FLORIDA ENDOCRINE & DIABETES ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11236 BAPTIST HEALTH DR SUITE 340
JACKSONVILLE FL
32218-2980
US

IV. Provider business mailing address

915 W MONROE ST SUITE 200
JACKSONVILLE FL
32204-1177
US

V. Phone/Fax

Practice location:
  • Phone: 904-384-2240
  • Fax: 904-486-2314
Mailing address:
  • Phone: 904-384-2240
  • Fax: 904-486-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENA CLAY
Title or Position: OFFICE MANAGER
Credential:
Phone: 904-384-2240