Healthcare Provider Details

I. General information

NPI: 1245472836
Provider Name (Legal Business Name): ASHWINI JASUTKAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W GRANADA BLVD
ORMOND BEACH FL
32174-9435
US

IV. Provider business mailing address

725 W GRANADA BLVD
ORMOND BEACH FL
32174-9435
US

V. Phone/Fax

Practice location:
  • Phone: 302-651-4000
  • Fax: 302-651-4000
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME128842
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: