Provider Demographics
NPI:1902124522
Name:JULINGTON CREEK PEDIATRICS
Entity Type:Organization
Organization Name:JULINGTON CREEK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSTELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-230-5437
Mailing Address - Street 1:774 STATE ROAD 13
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3857
Mailing Address - Country:US
Mailing Address - Phone:904-230-5437
Mailing Address - Fax:904-230-7337
Practice Address - Street 1:774 STATE ROAD 13
Practice Address - Street 2:SUITE 6
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-3857
Practice Address - Country:US
Practice Address - Phone:904-230-5437
Practice Address - Fax:904-230-7337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74170174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1679682264OtherTRICARE