Healthcare Provider Details

I. General information

NPI: 1285613315
Provider Name (Legal Business Name): JOHN EDWARD PRIOLEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD STE 300
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-4082
  • Fax: 904-819-5056
Mailing address:
  • Phone: 904-819-4082
  • Fax: 904-819-5056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME94505
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME94505
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME94505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: