Provider Demographics
NPI:1609858927
Name:BESTIC, MICA DAWN (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:MICA
Middle Name:DAWN
Last Name:BESTIC
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ11319Medicare UPIN
FLU1906YMedicare ID - Type Unspecified