Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PP0204X | Pediatric Emergency Physician | ME120640 | FL |
N | 208000000X | Pediatrician | ME120640 | FL |
NPI | 1497043046 |
---|---|
Provider Name | Dr. Marie Angeline Antonyrajah |
First Address | Jacksonville, FL 32256-0532 |
Second Address | Orlando, FL 32827-7402 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2011 |
Last Update Date | 13/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
014412800 | (05) | FL |