Provider Demographics
NPI:1053369215
Name:GARGIN, KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GARGIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9770 BAYMEADOWS RD.
Mailing Address - Street 2:SUITE 115
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-641-5550
Mailing Address - Fax:904-641-5520
Practice Address - Street 1:9770 BAYMEADOWS RD.
Practice Address - Street 2:SUITE 115
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-641-5550
Practice Address - Fax:904-641-5520
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77883OtherBCBSF
FLP00239386OtherRRMCR
FL77883OtherBCBSF
FLI39031Medicare UPIN