Provider Demographics
NPI:1710494000
Name:JACKSONVILLE LUNG CLINIC PLLC
Entity Type:Organization
Organization Name:JACKSONVILLE LUNG CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:PULIDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-513-3240
Mailing Address - Street 1:2624 ATLANTIC BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3633
Mailing Address - Country:US
Mailing Address - Phone:904-513-3240
Mailing Address - Fax:904-398-7871
Practice Address - Street 1:2624 ATLANTIC BLVD STE 6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3633
Practice Address - Country:US
Practice Address - Phone:904-513-3240
Practice Address - Fax:904-253-3098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02227440Medicaid