Healthcare Provider Details

I. General information

NPI: 1790086429
Provider Name (Legal Business Name): HARBOUR ISLAND PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S SUITE 106-B
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

2250 CAVALRY BLVD
JACKSONVILLE FL
32246-4201
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-8906
  • Fax: 904-461-8907
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-282-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME71363
License Number StateFL

VIII. Authorized Official

Name: DR. HOMERO VARELA SICANGCO JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-282-6331