Healthcare Provider Details

I. General information

NPI: 1578727970
Provider Name (Legal Business Name): ALLISON H MABUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 COUNTY ROAD 210 W. SUITE 122
FRUITE COVE FL
32259-4080
US

IV. Provider business mailing address

2851 COUNTY ROAD 210 W. SUITE 122
FRUITE COVE FL
32259-4080
US

V. Phone/Fax

Practice location:
  • Phone: 904-450-8120
  • Fax: 904-450-8119
Mailing address:
  • Phone: 904-450-8120
  • Fax: 904-450-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN 13081
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: