MEDICARE: FIRST COAST CARDIOVASCULAR INSTITUTE, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207RC0000X	Cardiovascular Disease Physician
2	207RC0001X	Clinical Cardiac Electrophysiology Physician
3	207RI0011X	Interventional Cardiology Physician
4	207RN0300X	Nephrology Physician
5	207RS0012X	Sleep Medicine (Internal Medicine) Physician
6	208600000X	Surgery Physician
7	207RC0000X	Cardiovascular Disease Physician	FL

General Provider Information

NPI Number	:	1659812394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST COAST CARDIOVASCULAR INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 551308
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32255-1308
Country	:	US
Telephone Number	:	904-493-3333
Fax Number	:	904-493-2222

Provider Business Practice Location Address
First Line	:	115 BARTRAM OAKS WALK STE 104
Second Line	:
City	:	FRUIT COVE
State	:	FL
Zip	:	32259-3247
Country	:	US
Telephone Number	:	904-493-3333
Fax Number	:	904-268-5505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. YAZAN KHATIB
Credential	:	MD
Telephone Number	:	904-493-3333

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	01/07/2025

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Directions to “FIRST COAST CARDIOVASCULAR INSTITUTE, LLC ” Practice Location

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