Healthcare Provider Details

I. General information

NPI: 1932444254
Provider Name (Legal Business Name): FLORIDA PHYSICIAN SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

IV. Provider business mailing address

3599 UNIVERSITY BLVD S SUITE 805
JACKSONVILLE FL
32216-4252
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-8418
  • Fax: 904-264-9692
Mailing address:
  • Phone: 904-309-8680
  • Fax: 904-345-5841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME59868
License Number StateFL

VIII. Authorized Official

Name: DR. MITCHELL D. TERK
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 904-309-8680