Healthcare Provider Details

I. General information

NPI: 1629322706
Provider Name (Legal Business Name): DOUGLAS RAYFIELD OGBURN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 MONUMENT RD SUITE A
JACKSONVILLE FL
32225
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 904-450-6600
  • Fax: 904-450-6369
Mailing address:
  • Phone: 904-396-6620
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106950
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9106950
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: