Healthcare Provider Details

I. General information

NPI: 1396415915
Provider Name (Legal Business Name): NORTH FLORIDA PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTH FLORIDA PEDIATRICS, PA 1101 OHIO AVENUE SOUTH
LIVE OAK FL
32064
US

IV. Provider business mailing address

1859 SW NEWLAND WAY
LAKE CITY FL
32025
US

V. Phone/Fax

Practice location:
  • Phone: 386-339-1060
  • Fax: 386-339-1067
Mailing address:
  • Phone: 386-758-0003
  • Fax: 386-755-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL SANTELICES
Title or Position: PRESIDENT/ CEO
Credential: MD.
Phone: 386-758-0003