Healthcare Provider Details

I. General information

NPI: 1336969948
Provider Name (Legal Business Name): STEVEN EDWARD GARDEAZABAL CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

12281 AUTUMNBROOK TRL E
JACKSONVILLE FL
32258-2389
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-8500
  • Fax:
Mailing address:
  • Phone: 904-982-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number100160957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: