MEDICARE: PEDIATRIC ASSOCIATES OF JULINGTON CREEK

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	208000000X	Pediatrics Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235276254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ASSOCIATES OF JULINGTON CREEK

Provider Business Mailing Address
First Line	:	1631 RACE TRACK ROAD SUITE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259
Country	:	US
Telephone Number	:	904-230-7977
Fax Number	:	904-230-7979

Provider Business Practice Location Address
First Line	:	1631 RACE TRACK RD STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-3233
Country	:	US
Telephone Number	:	904-230-7977
Fax Number	:	904-230-7979

Authorized Official
Title or Position	:	CEO
Name	:	DR. MARY ANN GARCIA
Credential	:	M.D.
Telephone Number	:	904-230-7977

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	08/22/2020

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1003893215 — KEVIN HOLTHAUS MD
Practice Location Address:

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Directions to “PEDIATRIC ASSOCIATES OF JULINGTON CREEK ” Practice Location

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