Provider Demographics
NPI:1316217896
Name:FLORIDA CENTER FOR INFECTIOUS DISEASES, INC.
Entity Type:Organization
Organization Name:FLORIDA CENTER FOR INFECTIOUS DISEASES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:904-322-1140
Mailing Address - Street 1:5055 MONROE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14810 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2451
Practice Address - Country:US
Practice Address - Phone:904-292-0863
Practice Address - Fax:904-212-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96311174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU8251YMedicare UPIN