Healthcare Provider Details

I. General information

NPI: 1205972460
Provider Name (Legal Business Name): JUAN LARROUDE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 US HIGHWAY 1 S SUITE 1
ST AUGUSTINE FL
32086-6351
US

IV. Provider business mailing address

3100 US HIGHWAY 1 S SUITE 1
ST AUGUSTINE FL
32086-6351
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-4990
  • Fax: 904-824-4990
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: JUAN LARROUDE
Title or Position: OWNER
Credential: MD
Phone: 904-797-2777