Provider Demographics
NPI:1578515359
Name:CEDRES, CARMELO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMELO
Middle Name:
Last Name:CEDRES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARMELO
Other - Middle Name:CEDRES
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-633-0460
Mailing Address - Fax:904-633-0461
Practice Address - Street 1:6271 SAINT AUGUSTINE RD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2555
Practice Address - Country:US
Practice Address - Phone:904-633-0460
Practice Address - Fax:904-633-0461
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10008672208000000X, 208D00000X
FLME53455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063341100Medicaid
FLC79091Medicare UPIN
FL063341100Medicaid
FL11564ZMedicare ID - Type Unspecified