W.B. Stewart Tigers Athletics Boosters

Primary specialty

Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X

Legal business name

W.B. STEWART TIGERS ATHLETICS BOOSTERS

Doing business as

EWC Sports Medicine

Practice address

1658 Kings Rd
Jacksonville, FL 32209-6167

Phone

(972) 367-4845

NPI assigned

Mar 19, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mouzon Bass

Title

Agent

Phone

(972) 367-4845

Specialties & licenses 1

Addresses

Other names 1

• EWC Sports Medicine Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1521417600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1521417600000",
    "number": "1841794682",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5050 SPRING VALLEY RD",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752443995"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1658 KINGS RD",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322096167",
            "telephone_number": "972-367-4845"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "W.B. STEWART TIGERS ATHLETICS BOOSTERS",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-03-19",
        "last_updated": "2018-03-19",
        "status": "A",
        "authorized_official_last_name": "BASS",
        "authorized_official_first_name": "MOUZON",
        "authorized_official_title_or_position": "AGENT",
        "authorized_official_telephone_number": "972-367-4845"
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "EWC Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Biagio V Vultaggio, MD
• Stephen Mario Vultaggio Jr., DDS
• Krina Dipak Vyas
• Darrell George Vydra, DO
• Nancy Kathryn Vynanek, RN
• W.P. Booras, M.D., P.a.
• Jeffrey Howard Wachholz, M.D.
• John Kelly Wachira, MD
• Noah Zachary Wacker
• Racquel Denise Waddy

• Pediatric Adolescent Medicine Physician in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Pediatric Adolescent Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.