Healthcare Provider Details

I. General information

NPI: 1215101902
Provider Name (Legal Business Name): 21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 SAN MARCO BLVD SUITE 3
JACKSONVILLE FL
32207-8554
US

IV. Provider business mailing address

2234 COLONIAL BLVD
FORT MYERS FL
33907-1412
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-5100
  • Fax: 904-493-5130
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL E. DOSORETZ
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 239-931-7275