Basic Information
Provider Information | |||||||||
NPI: | 1003898982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRINKMAN | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11945 SAN JOSE BLVD | ||||||||
Address2: | BLDG 300 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322231627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043961725 | ||||||||
FaxNumber: | 9043991717 | ||||||||
Practice Location | |||||||||
Address1: | 1555 KINGSLEY AVE | ||||||||
Address2: | SUITE 503 | ||||||||
City: | ORANGE PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 320739207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042785088 | ||||||||
FaxNumber: | 9042644910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 08/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 17275 | NE | N |   | Other Service Providers | Specialist |   | 208600000X | ME66544 | FL | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 4506932 | 01 | FL | AETNA | OTHER | 47072366813 | 05 | NE |   | MEDICAID | 020029570 | 01 | FL | RAILROAD MEDICARE | OTHER | 25509 | 01 | FL | BCBS FL | OTHER | 275828800 | 05 | FL |   | MEDICAID | 9912625 | 01 | FL | CIGNA | OTHER | 239210 | 01 | FL | AVMED | OTHER |