Healthcare Provider Details

I. General information

NPI: 1255858650
Provider Name (Legal Business Name): JOHN MATTHEW DUMAS CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 NEWCOMB RD
JACKSONVILLE FL
32218-1510
US

IV. Provider business mailing address

3640 NEWCOMB RD
JACKSONVILLE FL
32218-1510
US

V. Phone/Fax

Practice location:
  • Phone: 586-764-7252
  • Fax:
Mailing address:
  • Phone: 586-764-7252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number2786
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: