Basic Information
| Provider Information | |||||||||
| NPI: | 1790086429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBOUR ISLAND PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 CAVALRY BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322464201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9042821550 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PLANTATION ISLAND DR S | ||||||||
| Address2: | SUITE 106-B | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320803108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044618906 | ||||||||
| FaxNumber: | 9044618907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2010 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | SICANGCO | ||||||||
| AuthorizedOfficialFirstName: | HOMERO | ||||||||
| AuthorizedOfficialMiddleName: | VARELA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042826331 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME71363 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.