Provider Demographics
NPI:1043270853
Name:AULTMAN, KATHI A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHI
Middle Name:A
Last Name:AULTMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:1680 EAGLE HARBOR PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4806
Practice Address - Country:US
Practice Address - Phone:904-264-9555
Practice Address - Fax:904-215-7960
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32583207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039579000Medicaid
FL039579000Medicaid
FL01284ZMedicare PIN