Provider Demographics
NPI:1114332962
Name:ADVANCED VASCULAR RESOURCES OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:ADVANCED VASCULAR RESOURCES OF JACKSONVILLE, LLC
Other - Org Name:AVR OF JACKSONVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ODARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-434-0050
Mailing Address - Street 1:1700 ELTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1752
Mailing Address - Country:US
Mailing Address - Phone:904-416-1540
Mailing Address - Fax:904-425-2137
Practice Address - Street 1:4253 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6121
Practice Address - Country:US
Practice Address - Phone:904-416-1540
Practice Address - Fax:904-425-2137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1205279122OtherNPI