Provider Demographics
NPI:1205039690
Name:DOCTORS INLET PEDIATRICS & PRIMARY CARE, PA
Entity Type:Organization
Organization Name:DOCTORS INLET PEDIATRICS & PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MILIND
Authorized Official - Middle Name:V
Authorized Official - Last Name:TILAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-298-1994
Mailing Address - Street 1:10175 FORTUNE PKWY UNIT 401
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6750
Mailing Address - Country:US
Mailing Address - Phone:904-298-1994
Mailing Address - Fax:904-298-1973
Practice Address - Street 1:10175 FORTUNE PKWY UNIT 401
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-298-1994
Practice Address - Fax:904-298-1973
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOCTORS INLET PEDIATRICS AND PRIMARY CARE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265248001Medicaid