Provider Demographics
NPI:1790086429
Name:HARBOUR ISLAND PEDIATRICS
Entity Type:Organization
Organization Name:HARBOUR ISLAND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMERO
Authorized Official - Middle Name:VARELA
Authorized Official - Last Name:SICANGCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-282-6331
Mailing Address - Street 1:2250 CAVALRY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4201
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-282-1550
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 106-B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-461-8906
Practice Address - Fax:904-461-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty