Healthcare Provider Details

I. General information

NPI: 1831155381
Provider Name (Legal Business Name): JOHN GREY O'NEILL III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12404 HATTON CHASE LN W
JACKSONVILLE FL
32258
US

IV. Provider business mailing address

12404 HATTON CHASE LN W
JACKSONVILLE FL
32258-4435
US

V. Phone/Fax

Practice location:
  • Phone: 904-386-3359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME87833
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME87833
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC55278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: