Provider Demographics
NPI:1740243377
Name:PRATT, EBONY N (MD)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:N
Last Name:PRATT
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3465 VILLAGE CENTER DR
Practice Address - Street 2:UFJP BRENTWOOD
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-8617
Practice Address - Country:US
Practice Address - Phone:904-355-1893
Practice Address - Fax:904-355-1818
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23590207Q00000X
FLME77430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2774020-00Medicaid
FLAB480ZMedicare PIN
FLP00383183Medicare PIN
FL2774020-00Medicaid