MEDICARE: INES KEVRIC O'SHAUGHNESSY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME121400	FL

General Provider Information

NPI Number	:	1740624188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INES KEVRIC O'SHAUGHNESSY MD

Provider Business Mailing Address
First Line	:	3200 3RD ST S STE 200
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6097
Country	:	US
Telephone Number	:	904-249-6110
Fax Number	:	904-249-6119

Provider Business Practice Location Address
First Line	:	3200 3RD ST S STE 200
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6097
Country	:	US
Telephone Number	:	904-249-6110
Fax Number	:	904-249-6119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2013
Last Update Date	:	07/21/2022

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