Provider Demographics
NPI:1962579474
Name:GARGUS, REGINA ANN KOLLMER (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:ANN KOLLMER
Last Name:GARGUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6014
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:5192 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2102
Practice Address - Country:US
Practice Address - Phone:850-416-2124
Practice Address - Fax:850-416-2126
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE44442080P0006X
TN441662080P0006X
FLME1311642080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1962579474OtherNPI
FL021603200Medicaid
AR158026001Medicaid
5N261Medicare PIN
FL021603200Medicaid