Healthcare Provider Details

I. General information

NPI: 1891031910
Provider Name (Legal Business Name): MANDARIN FAMILY MEDICINE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

12276-210 SAN JOSE BLVD
JACKSONVILLE FL
32223
US

IV. Provider business mailing address

12276-210 SAN JOSE BLVD
JACKSONVILLE FL
32223
US

V. Phone/Fax

Practice location:
  • Phone: 904-268-9266
  • Fax: 904-292-1482
Mailing address:
  • Phone: 904-268-9266
  • Fax: 904-292-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberOS3739
License Number StateFL

VIII. Authorized Official

Name: DR. RODNEY A MARCOM
Title or Position: DOCTOR
Credential: D.O.
Phone: 904-268-9266