Healthcare Provider Details

I. General information

NPI: 1710940648
Provider Name (Legal Business Name): ANASTASIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DRIVE SUITE 203A
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DRIVE SUITE 203A
ST AUGUSTINE FL
32080
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-0821
  • Fax: 904-461-0823
Mailing address:
  • Phone: 904-461-0821
  • Fax: 904-461-0823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: SUHAS P NEERUKONDA
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 904-461-0343