Provider Demographics
NPI:1316915663
Name:ETTEDGUI, JOSE ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ALBERTO
Last Name:ETTEDGUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:
Practice Address - Street 1:841 PRUDENTIAL DR STE 280
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8350
Practice Address - Country:US
Practice Address - Phone:904-202-8550
Practice Address - Fax:904-393-7808
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME863782080P0202X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2637286-00Medicaid
GA000723269AMedicaid
FL2637286-00Medicaid
GA000723269AMedicaid
FL13361XMedicare PIN
FLE67692Medicare UPIN
FL13361ZMedicare PIN