Healthcare Provider Details

I. General information

NPI: 1336194414
Provider Name (Legal Business Name): KEVIN C JONES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 CARRIAGE LAMP WAY
PONTE VEDRA BEACH FL
32082-1903
US

IV. Provider business mailing address

129 CARRIAGE LAMP WAY
PONTE VEDRA BEACH FL
32082-1903
US

V. Phone/Fax

Practice location:
  • Phone: 904-728-8825
  • Fax:
Mailing address:
  • Phone: 904-728-8825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number53764
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number205663-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMMD.28538 MD
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME 88907
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: