Healthcare Provider Details

I. General information

NPI: 1073870341
Provider Name (Legal Business Name): FLORIDA CENTER FOR DERMATOLOGY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SOUTHPARK BLVD SUITE A103
ST AUGUSTINE FL
32086-5191
US

IV. Provider business mailing address

105 SOUTHPARK BLVD SUITE A103
ST AUGUSTINE FL
32086-5191
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-7765
  • Fax: 904-342-7770
Mailing address:
  • Phone: 904-342-7765
  • Fax: 904-342-7770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME92201
License Number StateFL

VIII. Authorized Official

Name: DR. JONATHAN KANTOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-342-7765