Healthcare Provider Details

I. General information

NPI: 1063883197
Provider Name (Legal Business Name): NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PLANTATION ISLAND DR S SUITE 1
ST AUGUSTINE FL
32080-6010
US

IV. Provider business mailing address

915 W MONROE ST SUITE 200
JACKSONVILLE FL
32204-1177
US

V. Phone/Fax

Practice location:
  • Phone: 904-384-2240
  • Fax: 394-384-6055
Mailing address:
  • Phone: 904-384-2240
  • Fax: 904-384-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELENA ORAVETZ
Title or Position: CREDENTIALING
Credential:
Phone: 904-384-2240