Healthcare Provider Details

I. General information

NPI: 1629185277
Provider Name (Legal Business Name): NORTHEAST FLOIDA STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 WILD GRAPE LN
ORANGE PARK FL
32003-7204
US

IV. Provider business mailing address

1820 WILD GRAPE LN
ORANGE PARK FL
32003-7204
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2606
  • Fax:
Mailing address:
  • Phone: 904-269-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberME27968
License Number StateFL

VIII. Authorized Official

Name: PROF. TORIBIO M. DUHAYLUNGSOD
Title or Position: SENIOR PHYSICIAN PSYCHIATRIST
Credential: M.D.
Phone: 904-259-6211