Healthcare Provider Details

I. General information

NPI: 1619993375
Provider Name (Legal Business Name): BRUCE HENRY PALEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
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:
Title or Position:
Credential:
Phone: