Healthcare Provider Details

I. General information

NPI: 1417953076
Provider Name (Legal Business Name): PAUL DAVID JAYACHANDRA M D P A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 OSCEOLA ELEMENTARY RD STE A
ST AUGUSTINE FL
32084-0968
US

IV. Provider business mailing address

1680 OSCEOLA ELEMENTARY RD STE A
ST AUGUSTINE FL
32084-0968
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 Code207RN0300X
TaxonomyNephrology Physician
License NumberME0066989
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: