Healthcare Provider Details

I. General information

NPI: 1700340106
Provider Name (Legal Business Name): ROBERT CHRISTOPHER SCALISE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 POTTERS MILL TRL
PONTE VEDRA FL
32081-1200
US

IV. Provider business mailing address

964 AJAX STREET MEDICAL CLINIC, OCCUPATIONAL HEALTH
JACKSONVILLE FL
32212
US

V. Phone/Fax

Practice location:
  • Phone: 619-882-9148
  • Fax:
Mailing address:
  • Phone: 904-542-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number5101018005
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number5101018005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: