Basic Information
| Provider Information | |||||||||
| NPI: | 1922335389 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSONVILLE MS AND NEUROLOGY CENTER, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17809 | ||||||||
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| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322457809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047235665 | ||||||||
| FaxNumber: | 9043380951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1895 KINGSLEY AVE STE 903 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042761663 | ||||||||
| FaxNumber: | 9042762469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | MAQUERA | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042761663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME59449 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 28344 | 01 | FL | BCBS | OTHER |