Basic Information
| Provider Information | |||||||||
| NPI: | 1497713614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | AGNES | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| 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: | 1370 13TH AVENUE | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042494994 | ||||||||
| FaxNumber: | 9042492604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME0069602 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1817346 | 01 | CIGNA | OTHER | 7726223 | 01 | AETNA | OTHER | 277501 | 01 | FL | AVMED | OTHER | 35919 | 01 | BCBS FL | OTHER | P00198232 | 01 | FL | RAILROAD MEDICARE | OTHER |