Healthcare Provider Details

I. General information

NPI: 1386728848
Provider Name (Legal Business Name): CARDIOVASCULAR CONSULTANTS OF ST AUGUSTINE PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD STE 5010
SAINT AUGUSTINE FL
32086-3705
US

IV. Provider business mailing address

3501B N PONCE DE LEON BLVD PMB 392
SAINT AUGUSTINE FL
32084-1400
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-8809
  • Fax: 904-823-8851
Mailing address:
  • Phone: 904-823-8809
  • Fax: 904-823-8851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME85299
License Number StateFL

VIII. Authorized Official

Name: DR. ALI TUTAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-823-8809