Provider Demographics
NPI:1609093426
Name:VLADIMIR HAVRYLIUK M D P A
Entity Type:Organization
Organization Name:VLADIMIR HAVRYLIUK M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRYLIUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-221-0014
Mailing Address - Street 1:13714 BROMLEY POINT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2634
Mailing Address - Country:US
Mailing Address - Phone:904-220-9448
Mailing Address - Fax:
Practice Address - Street 1:8818 ARLINGTON EXPY
Practice Address - Street 2:B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-8071
Practice Address - Country:US
Practice Address - Phone:904-221-0014
Practice Address - Fax:904-221-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherCOMMERCIAL
FL57838Medicare ID - Type Unspecified
FLH79187Medicare UPIN