Healthcare Provider Details

I. General information

NPI: 1992715130
Provider Name (Legal Business Name): JASON JACOB SKIWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

PO BOX 12938 C/O CLINIC MANAGEMENT
CALHOUN GA
30703-7013
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0410
  • Fax: 407-975-0407
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number64973
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME163346
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: