Healthcare Provider Details

I. General information

NPI: 1356502421
Provider Name (Legal Business Name): JOHANNA MARIE KIELBASA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13535 NEMOURS PKWY
ORLANDO FL
32827-7402
US

IV. Provider business mailing address

10140 CENTURION PARKWAY N.
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 407-567-4000
  • Fax: 407-567-5924
Mailing address:
  • Phone: 904-697-4127
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number149579
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28708
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME132856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: