Healthcare Provider Details

I. General information

NPI: 1659669901
Provider Name (Legal Business Name): JAMESON HENRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

IV. Provider business mailing address

PO BOX 864074
ORLANDO FL
32886-4074
US

V. Phone/Fax

Practice location:
  • Phone: 386-254-4000
  • Fax: 386-226-4577
Mailing address:
  • Phone: 386-226-4590
  • Fax: 386-226-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT200415
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME120866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: