Healthcare Provider Details

I. General information

NPI: 1265506083
Provider Name (Legal Business Name): DR. ANTHONY J MUSSALLEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 02/08/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ST AUGUSTINE SOUTH DRIVE
ST AUGUSTINE FL
32086
US

IV. Provider business mailing address

100 ST AUGUSTINE SOUTH DRIVE
ST AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-3785
  • Fax: 904-797-3789
Mailing address:
  • Phone: 904-797-3785
  • Fax: 904-797-3789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME124001
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: