Provider Demographics
NPI:1346322427
Name:PHELPS MAXWELL, JULIETTE RISTALINE I (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIETTE
Middle Name:RISTALINE
Last Name:PHELPS MAXWELL
Suffix:I
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 1:8451 GATE PKWY W APT 1320
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4106
Mailing Address - Country:US
Mailing Address - Phone:740-526-0139
Mailing Address - Fax:
Practice Address - Street 1:1833 BOULEVARD
Practice Address - Street 2:VA OUTPATIENT CLINIC
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4382
Practice Address - Country:US
Practice Address - Phone:740-453-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071084207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0294051Medicaid
OHMA2016451Medicare ID - Type Unspecified
OH0294051Medicaid