Provider Demographics
NPI:1972609345
Name:MALESIC, IRENE ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ELAINE
Last Name:MALESIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:IRENE
Other - Middle Name:MALESIC
Other - Last Name:PEZZUTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12412 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8620
Mailing Address - Country:US
Mailing Address - Phone:904-292-4755
Mailing Address - Fax:904-292-9243
Practice Address - Street 1:12412 SAN JOSE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8620
Practice Address - Country:US
Practice Address - Phone:904-292-4755
Practice Address - Fax:904-292-9243
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL36753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15570OtherBCBS
FL15570OtherBCBS