Healthcare Provider Details

I. General information

NPI: 1437568482
Provider Name (Legal Business Name): BRUCE H PALEY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 OLD MOULTRIE RD SUITE B
ST AUGUSTINE FL
32084-4168
US

IV. Provider business mailing address

1851 OLD MOULTRIE RD SUITE B
ST AUGUSTINE FL
32084-4168
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8088
  • Fax: 904-826-4105
Mailing address:
  • Phone: 904-824-8088
  • Fax: 904-826-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS5622
License Number StateFL

VIII. Authorized Official

Name: DR. BRUCE HENRY PALEY
Title or Position: PRESIDENT OF PA
Credential: DO
Phone: 904-824-8088