Provider Demographics
NPI:1467590711
Name:ST. JOHN'S PEDIATRICS, PA
Entity Type:Organization
Organization Name:ST. JOHN'S PEDIATRICS, PA
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:904-807-9112
Mailing Address - Street 1:161 HAMPTON POINT DRIVE STE 4
Mailing Address - Street 2:
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 DRIVE STE 4
Practice Address - Street 2:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28637OtherBCBS