Healthcare Provider Details

I. General information

NPI: 1841463601
Provider Name (Legal Business Name): ROBERT B DEHGAN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 CRILL AVE
PALATKA FL
32177-6807
US

IV. Provider business mailing address

460 OSCEOLA AVE
JACKSONVILLE FL
32250-4078
US

V. Phone/Fax

Practice location:
  • Phone: 386-325-0570
  • Fax:
Mailing address:
  • Phone: 904-247-1919
  • Fax: 904-246-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberME16903
License Number StateFL

VIII. Authorized Official

Name: ROBERT B DEHGAN
Title or Position: CEO/ OWNER
Credential: MD
Phone: 904-794-9180