Healthcare Provider Details

I. General information

NPI: 1467590711
Provider Name (Legal Business Name): ST. JOHN'S PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 HAMPTON POINT DRIVE STE 4
SAINT AUGUSTINE FL
32092-3057
US

IV. Provider business mailing address

161 HAMPTON POINT DRIVE STE 4
SAINT AUGUSTINE FL
32092-3057
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-0624
  • Fax: 904-230-7947
Mailing address:
  • Phone: 904-230-0624
  • Fax: 904-230-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90096
License Number StateFL

VIII. Authorized Official

Name: DR. LETICIA ROSARIO ABREA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-807-9112