Provider Demographics
NPI:1699827139
Name:NORTHEAST FLORIDA PEDIATRIC ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA PEDIATRIC ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA-ARIET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-221-4325
Mailing Address - Street 1:13595 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3256
Mailing Address - Country:US
Mailing Address - Phone:904-221-4325
Mailing Address - Fax:904-221-9167
Practice Address - Street 1:13595 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3256
Practice Address - Country:US
Practice Address - Phone:904-221-4325
Practice Address - Fax:904-221-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004418500Medicaid