Provider Demographics
NPI:1780071613
Name:CLAY PULMONARY SERVICES PA
Entity type:Organization
Organization Name:CLAY PULMONARY SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONIO-MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-269-9200
Mailing Address - Street 1:1409 KINGSLEY AVE
Mailing Address - Street 2:BUILDING 3B
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4537
Mailing Address - Country:US
Mailing Address - Phone:904-269-9200
Mailing Address - Fax:904-269-7796
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:BUILDING 3B
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-269-9200
Practice Address - Fax:904-269-7796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74314207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty