Provider Demographics
NPI:1861791402
Name:ADVANCED EAR, NOSE, THROAT ASSOCIATES, LLC
Entity type:Organization
Organization Name:ADVANCED EAR, NOSE, THROAT ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KUNAL
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-339-0350
Mailing Address - Street 1:1560 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3222
Mailing Address - Country:US
Mailing Address - Phone:904-339-0350
Mailing Address - Fax:904-339-0351
Practice Address - Street 1:1560 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3222
Practice Address - Country:US
Practice Address - Phone:904-339-0350
Practice Address - Fax:904-339-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104096207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty