Provider Demographics
NPI:1215932520
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:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORAVETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-384-2240
Mailing Address - Street 1:915 WEST MONROE STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1177
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-384-6055
Practice Address - Street 1:915 WEST MONROE STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1177
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:2005-06-15
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374606200Medicaid
FL77240Medicare ID - Type Unspecified
FL374606200Medicaid
FL5497720001Medicare NSC