Healthcare Provider Details

I. General information

NPI: 1649280041
Provider Name (Legal Business Name): ZANE GARY KALTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 TURIN TER STE 220
ST AUGUSTINE FL
32092-0850
US

IV. Provider business mailing address

PO BOX 3266
ST AUGUSTINE FL
32085-3266
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-3000
  • Fax: 904-819-3201
Mailing address:
  • Phone: 904-819-4602
  • Fax: 904-819-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2012-00665
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0026524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: