Healthcare Provider Details

I. General information

NPI: 1770427171
Provider Name (Legal Business Name): SAINT JOHNS PLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 ASHOURIAN AVE STE 107
SAINT AUGUSTINE FL
32092-5110
US

IV. Provider business mailing address

512 COURTNEY OAKS DR
SAINT AUGUSTINE FL
32092-1999
US

V. Phone/Fax

Practice location:
  • Phone: 281-630-1127
  • Fax:
Mailing address:
  • Phone: 281-630-1127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW BRETT MITCHELL
Title or Position: MEMBER/PLASTIC SURGEON
Credential: MD
Phone: 904-657-4103