Healthcare Provider Details

I. General information

NPI: 1700349586
Provider Name (Legal Business Name): JOHANNA RUIZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5156
US

IV. Provider business mailing address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

V. Phone/Fax

Practice location:
  • Phone: 904-629-2000
  • Fax: 904-629-2015
Mailing address:
  • Phone: 904-639-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME157717
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: