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General NPI Number Information
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NPI Number | 1467471672
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Entity Type | Organization
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Legal Business Name | CLINIC FOR KIDNEY DISEASES PA
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 01/20/2010
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Provider Practice Location Address
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Address Line | 2585 HERSCHEL ST
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4557
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Country | US
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Telephone | 904-388-2678
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Fax | 904-388-6776
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Provider Business Mailing Address
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Address Line | 2585 HERSCHEL ST
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4557
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Country | US
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Telephone | 904-388-2678
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Fax | 904-388-6776
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DINESH JAYADEVAPPA
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Credential | MD
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Telephone | 904-388-2678
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | ME24762
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License Number State | FL
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