Healthcare Provider Details

I. General information

NPI: 1295870830
Provider Name (Legal Business Name): PAUL D JAYACHANDRA M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 OSCEOLA ELEMENTARY SCHOOL ROAD SUITE A
ST AUGUSTINE FL
32084
US

IV. Provider business mailing address

1680 OSCEOLA ELEMENTARY SCHOOL ROAD SUITE A
ST AUGUSTINE FL
32084
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7476
  • Fax: 904-824-7870
Mailing address:
  • Phone: 904-824-7476
  • Fax: 904-824-7870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0066989
License Number StateFL

VIII. Authorized Official

Name: JENNIFER RAE FAIRCLOTH
Title or Position: OFFICE MANAGER
Credential: L P N
Phone: 904-824-7476