Provider Demographics
NPI:1659506319
Name:SHUGARMAN, ILICIA LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:ILICIA
Middle Name:LAUREN
Last Name:SHUGARMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 A C SKINNER PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:700 3RD ST STE 302
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5082
Practice Address - Country:US
Practice Address - Phone:904-997-3800
Practice Address - Fax:904-997-3899
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN13818207R00000X
FLME122974207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014413900Medicaid
FL14ZM4OtherBC/BS
FL014413900Medicaid