Provider Demographics
NPI:1811954126
Name:PEDIATRIC ASSOCIATES OF JACKSONVILLE, PA
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF JACKSONVILLE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AYLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OZDEMIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-273-6533
Mailing Address - Street 1:2 FAIRFIELD BLVD
Mailing Address - Street 2:SUITE #11
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4626
Mailing Address - Country:US
Mailing Address - Phone:904-273-6533
Mailing Address - Fax:904-280-7369
Practice Address - Street 1:2 FAIRFIELD BLVD
Practice Address - Street 2:SUITE #11
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4626
Practice Address - Country:US
Practice Address - Phone:904-273-6533
Practice Address - Fax:904-280-7369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
99995OtherBLUECROSS BLUESHIELD