Healthcare Provider Details

I. General information

NPI: 1043888985
Provider Name (Legal Business Name): MAGNIFYDX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EXECUTIVE WAY STE 114
PONTE VEDRA BEACH FL
32082-2713
US

IV. Provider business mailing address

100 EXECUTIVE WAY STE 114
PONTE VEDRA BEACH FL
32082-2713
US

V. Phone/Fax

Practice location:
  • Phone: 904-842-3632
  • Fax:
Mailing address:
  • Phone: 904-842-3632
  • Fax: 877-624-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK CAPPEL
Title or Position: OWNER
Credential: MD
Phone: 904-686-7771