Healthcare Provider Details

I. General information

NPI: 1235232273
Provider Name (Legal Business Name): NORTHEAST FLORIDA PRIMARY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 EAST-WEST PARKWAY SUITE 11
ORANGE PARK FL
32003
US

IV. Provider business mailing address

1835 EAST-WEST PARKWAY SUITE 11
ORANGE PARK FL
32003
US

V. Phone/Fax

Practice location:
  • Phone: 904-215-9266
  • Fax: 904-264-4651
Mailing address:
  • Phone: 904-215-9266
  • Fax: 904-264-4651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0076341
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0068123
License Number StateFL

VIII. Authorized Official

Name: DR. JACK EDWARD PULWERS JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 904-215-9266