Provider Demographics
NPI:1699708735
Name:ST. AUGUSTINE EAR, NOSE & THROAT, L.L.C.
Entity type:Organization
Organization Name:ST. AUGUSTINE EAR, NOSE & THROAT, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALPANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEPASQUALE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-461-6060
Mailing Address - Street 1:1301 PLANTATION ISLAND DRIVE
Mailing Address - Street 2:UNIT 401
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080
Mailing Address - Country:US
Mailing Address - Phone:904-461-6060
Mailing Address - Fax:904-461-6622
Practice Address - Street 1:1301 PLANTATION ISLAND DRIVE
Practice Address - Street 2:UNIT 401
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-461-6060
Practice Address - Fax:904-461-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8839174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4759Medicare ID - Type Unspecified