Basic Information
Provider Information | |||||||||
NPI: | 1750443412 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTRICHARD | ||||||||
FirstName: | MAY | ||||||||
MiddleName: | ELLZA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6841 BLANDING BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322444418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048622175 | ||||||||
FaxNumber: | 3056986536 | ||||||||
Practice Location | |||||||||
Address1: | 6841 BLANDING BLVD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 32244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048622175 | ||||||||
FaxNumber: | 3056986536 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2006 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME72631 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 593586793 | 01 | FL | AMERICAN HERITAGE LIFE | OTHER | 32845 | 01 | FL | BCBS OF FLORIDA | OTHER | 206872 | 01 | FL | AVMED | OTHER | 593586793 | 01 | FL | TRICARE | OTHER | 5415612 | 01 | FL | AETNA | OTHER | 593586793 | 01 | FL | BANKERS LIFE & CASUALTY | OTHER | 593586793 | 01 | FL | CHAMPUS | OTHER | 593586793 | 01 | FL | UNITED HEALTHCARE | OTHER | 593586793 | 01 | FL | FIRST HEALTH NETWORK | OTHER | 593586793 | 01 | FL | AARP HEALTH CARE OPTIONS | OTHER | 593586793 | 01 | FL | PRIVATE HEALTHCARE SYSTEM | OTHER | 593586793 | 01 | FL | CIGNA | OTHER | 593586793 | 01 | FL | HUMANA | OTHER | 593586793 | 01 | FL | VISTA HEALTHPLAN | OTHER |