Provider Demographics
NPI:1386843506
Name:ST. JOHN'S PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:ST. JOHN'S PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:ROSARIO
Authorized Official - Last Name:ABREA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-230-0624
Mailing Address - Street 1:161 HAMPTON POINT DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3057
Mailing Address - Country:US
Mailing Address - Phone:904-230-0624
Mailing Address - Fax:904-230-7947
Practice Address - Street 1:161 HAMPTON POINT DR
Practice Address - Street 2:SUITE 4
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3057
Practice Address - Country:US
Practice Address - Phone:904-230-0624
Practice Address - Fax:904-230-7947
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN'S PEDIATRICS, P.A. MAIN OFFICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty