Provider Demographics
NPI:1548530736
Name:CHILDREN'S EXPRESS CARE CLINIC
Entity type:Organization
Organization Name:CHILDREN'S EXPRESS CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUWARNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TILAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-519-0008
Mailing Address - Street 1:10175 FORTUNE PKWY UNIT 402
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6750
Mailing Address - Country:US
Mailing Address - Phone:904-519-0008
Mailing Address - Fax:904-379-7312
Practice Address - Street 1:430 COLLEGE DR UNIT 100-102
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8530
Practice Address - Country:US
Practice Address - Phone:904-644-8669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL604727208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty