Healthcare Provider Details

I. General information

NPI: 1205871001
Provider Name (Legal Business Name): PARK AVENUE DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 PARK AVE
ORANGE PARK FL
32073-4120
US

IV. Provider business mailing address

906 PARK AVE
ORANGE PARK FL
32073-4120
US

V. Phone/Fax

Practice location:
  • Phone: 904-541-0315
  • Fax: 904-541-0316
Mailing address:
  • Phone: 904-541-0315
  • Fax: 904-541-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS 4926
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS 4926
License Number StateFL

VIII. Authorized Official

Name: GEORGE J SCHMIEDER
Title or Position: PRESIDENT
Credential: D.O.
Phone: 904-541-0315