Provider Demographics
NPI:1164592218
Name:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC CENTER OF JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICOLAU
Authorized Official - Middle Name:
Authorized Official - Last Name:SACAQUINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-731-1556
Mailing Address - Street 1:PO BOX 5606
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-5606
Mailing Address - Country:US
Mailing Address - Phone:904-287-6263
Mailing Address - Fax:904-287-6213
Practice Address - Street 1:1400 BISHOP ESTATES RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-4244
Practice Address - Country:US
Practice Address - Phone:904-287-6263
Practice Address - Fax:904-287-6213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC53312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2764OtherBCBS PROVIDER NUMBER