Healthcare Provider Details

I. General information

NPI: 1265600365
Provider Name (Legal Business Name): MARYAM QADIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5135
US

IV. Provider business mailing address

PO BOX 1779
ST AUGUSTINE FL
32085-1779
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-8300
  • Fax: 904-829-8310
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME116652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: