Healthcare Provider Details

I. General information

NPI: 1306035951
Provider Name (Legal Business Name): JACKSONVILLE OTOLARYNGOLOGY & FACIAL PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR STE 807
JACKSONVILLE FL
32207-8335
US

IV. Provider business mailing address

836 PRUDENTIAL DR STE 807
JACKSONVILLE FL
32207-8335
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-8060
  • Fax: 904-396-9700
Mailing address:
  • Phone: 904-396-8060
  • Fax: 904-396-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME #90519
License Number StateFL

VIII. Authorized Official

Name: JULIANN P CANNON
Title or Position: OFFICE MANAGER
Credential:
Phone: 904-396-8060