Provider Demographics
NPI:1497713614
Name:DAVID, AGNES G (M D)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:G
Last Name:DAVID
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:1370 13TH AVENUE
Practice Address - Street 2:SUITE 119
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3206
Practice Address - Country:US
Practice Address - Phone:904-249-4994
Practice Address - Fax:904-249-2604
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069602208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1817346OtherCIGNA
7726223OtherAETNA
FL277501OtherAVMED
35919OtherBCBS FL
FLP00198232OtherRAILROAD MEDICARE
H29092Medicare UPIN
FL277501OtherAVMED