Healthcare Provider Details

I. General information

NPI: 1912373663
Provider Name (Legal Business Name): MR. JOSEPH PEZAK JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 A1A BEACH BLVD
ST AUGUSTINE FL
32080-6724
US

IV. Provider business mailing address

1013 A1A BEACH BLVD
ST AUGUSTINE FL
32080-6724
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-0931
  • Fax: 904-460-0932
Mailing address:
  • Phone: 904-460-0931
  • Fax: 904-460-0932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS4229
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberF03244
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: