Healthcare Provider Details

I. General information

NPI: 1609424217
Provider Name (Legal Business Name): NORTH FLORIDA PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 HILDEN ROAD SUITE 101
PONTE VEDRA FL
32081
US

IV. Provider business mailing address

1859 SW NEWLAND WAY
LAKE CITY FL
32025
US

V. Phone/Fax

Practice location:
  • Phone: 904-393-4700
  • Fax: 904-493-9700
Mailing address:
  • Phone: 386-758-0003
  • Fax: 386-755-4432

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: MR. SAMUEL SANTELICES
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 386-758-0003