Healthcare Provider Details

I. General information

NPI: 1205878725
Provider Name (Legal Business Name): ORANGE PARK PEDIATRIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 SMITH ST
ORANGE PARK FL
32073-5554
US

IV. Provider business mailing address

2140 SMITH ST
ORANGE PARK FL
32073-5554
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2145
  • Fax: 904-278-5038
Mailing address:
  • Phone: 904-269-2145
  • Fax: 904-278-5038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MAGGIE MACY
Title or Position: SUPERVISOR
Credential:
Phone: 904-269-2145