Healthcare Provider Details

I. General information

NPI: 1962316315
Provider Name (Legal Business Name): KAWA DIRECT PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 SUMMERLIN LN STE 107
ST AUGUSTINE FL
32095-8160
US

IV. Provider business mailing address

45 SUMMERLIN LN STE 107
ST AUGUSTINE FL
32095-8160
US

V. Phone/Fax

Practice location:
  • Phone: 904-817-0067
  • Fax:
Mailing address:
  • Phone: 904-817-0067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT KAWA
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: DO
Phone: 843-446-9712