Healthcare Provider Details

I. General information

NPI: 1265650295
Provider Name (Legal Business Name): JEREMY ALAN CAUDILL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 OLD MOULTRIE RD STE 3
SAINT AUGUSTINE FL
32086-4198
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 3
SAINT AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-6627
  • Fax: 386-328-4125
Mailing address:
  • Phone: 904-797-6627
  • Fax: 904-797-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS10861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: