MEDICARE: SIVANTA J PAUL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	ME56495	FL
2	2084P0800X	Psychiatry Physician	ME56495	FL

General Provider Information

NPI Number	:	1215978887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIVANTA J PAUL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 19949
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32245-0949
Country	:	US
Telephone Number	:	904-279-1666
Fax Number	:	904-279-1665

Provider Business Practice Location Address
First Line	:	6817 SOUTHPOINT PKWY STE 703
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6280
Country	:	US
Telephone Number	:	904-279-1666
Fax Number	:	904-279-1665

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	03/09/2020

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