Healthcare Provider Details

I. General information

NPI: 1205505633
Provider Name (Legal Business Name): NORTH FLORIDA PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 EAST CALL STREET
STARKE FL
32091
US

IV. Provider business mailing address

1859 SW NEWLAND WAY
LAKE CITY FL
32025
US

V. Phone/Fax

Practice location:
  • Phone: 904-368-0368
  • Fax: 904-317-4949
Mailing address:
  • Phone: 386-758-0003
  • Fax: 386-755-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL SANTELICES
Title or Position: PRESIDENT / CEO
Credential:
Phone: 386-758-0003