Healthcare Provider Details

I. General information

NPI: 1710246483
Provider Name (Legal Business Name): JAY PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14088 ALABAMA ST
JAY FL
32565-1036
US

IV. Provider business mailing address

PO BOX 10
JAY FL
32565-0010
US

V. Phone/Fax

Practice location:
  • Phone: 850-675-4546
  • Fax: 850-675-4548
Mailing address:
  • Phone: 850-675-4546
  • Fax: 850-675-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME68044
License Number StateFL

VIII. Authorized Official

Name: MARIAN B STEWART
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 850-675-4546