MEDICARE: DR. JOSE ALBERTO ETTEDGUI 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	2080P0202X	Pediatric Cardiology Physician	ME86378	FL
2	208000000X	Pediatrics Physician	ME86378	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316915663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE ALBERTO ETTEDGUI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 40767
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32203-0767
Country	:	US
Telephone Number	:	904-376-3707
Fax Number	:

Provider Business Practice Location Address
First Line	:	841 PRUDENTIAL DR STE 280
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8350
Country	:	US
Telephone Number	:	904-202-8550
Fax Number	:	904-393-7808

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

Provider Enumeration Date	:	03/12/2006
Last Update Date	:	05/11/2023

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Directions to “ DR. JOSE ALBERTO ETTEDGUI M.D.” Practice Location

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