Healthcare Provider Details

I. General information

NPI: 1336553619
Provider Name (Legal Business Name): PRECISION DERMATOLOGY AND SKIN SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 RIVERSIDE AVE
JACKSONVILLE FL
32204-4161
US

IV. Provider business mailing address

1550 RIVERSIDE AVE STE A
JACKSONVILLE FL
32204-4162
US

V. Phone/Fax

Practice location:
  • Phone: 904-613-3966
  • Fax:
Mailing address:
  • Phone: 904-923-6647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME76595
License Number StateFL

VIII. Authorized Official

Name: ANGIE HUBBARD
Title or Position: MANAGER
Credential:
Phone: 904-716-5102