Healthcare Provider Details

I. General information

NPI: 1669640348
Provider Name (Legal Business Name): KENNETH LESLIE GAGE M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

12902 USF MAGNOLIA DR MAILSTOP WCB-RAD MD/OPI
TAMPA FL
33612-9416
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2000
  • Fax:
Mailing address:
  • Phone: 813-745-1573
  • Fax: 813-745-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME119590
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME119590
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME119590
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: