Healthcare Provider Details

I. General information

NPI: 1669482188
Provider Name (Legal Business Name): ASHFAQ LATIF KUDIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 302A
ST AUGUSTINE FL
32080-3117
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 302A
ST AUGUSTINE FL
32080-3117
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-9330
  • Fax: 904-461-9331
Mailing address:
  • Phone: 904-461-9330
  • Fax: 904-461-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0068850
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: