Healthcare Provider Details

I. General information

NPI: 1972016210
Provider Name (Legal Business Name): RUSSELL DENEA, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 A1A S
SAINT AUGUSTINE FL
32080-6942
US

IV. Provider business mailing address

4102 A1A S
SAINT AUGUSTINE FL
32080-6942
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-1300
  • Fax: 904-471-1333
Mailing address:
  • Phone: 904-471-1300
  • Fax: 904-471-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL DENEA
Title or Position: OWNER
Credential: MD
Phone: 904-471-1300