Healthcare Provider Details

I. General information

NPI: 1639437569
Provider Name (Legal Business Name): COMMUNITY CARE PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2012
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 US 1 SOUTH STE 300 B
SAINT AUGUSTINE FL
32086
US

IV. Provider business mailing address

3670 US 1 SOUTH STE 300 B
SAINT AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-479-9501
  • Fax: 904-217-0524
Mailing address:
  • Phone: 904-479-9501
  • Fax: 904-217-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUIS ANDERSON
Title or Position: MD/PRESIDENT/OWNER
Credential: MD
Phone: 904-479-9501