Provider Demographics
NPI:1912108721
Name:NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA
Entity Type:Organization
Organization Name:NORTHEAST FLORIDA ENDOCRINE AND DIABETES ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-384-2240
Mailing Address - Street 1:1635 EAGLE HARBOR PARKWAY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FLEMING ISLANG
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4827
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-384-6055
Practice Address - Street 1:1635 EAGLE HARBOR PARKWAY
Practice Address - Street 2:SUITE 5
Practice Address - City:FLEMING ISLANG
Practice Address - State:FL
Practice Address - Zip Code:32003-4827
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-384-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FL5497720001332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374606200Medicaid
FL77240Medicare PIN
FL374606200Medicaid