Healthcare Provider Details

I. General information

NPI: 1700059623
Provider Name (Legal Business Name): ROBERT B DEHGAN M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ORTHOPAEDIC PL
ST AUGUSTINE FL
32086-4202
US

IV. Provider business mailing address

460 OSCEOLA AVE
JACKSONVILLE FL
32250-4078
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-1919
  • Fax: 904-246-0301
Mailing address:
  • Phone: 904-247-1919
  • Fax: 904-246-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME16903
License Number StateFL

VIII. Authorized Official

Name: ROBERT B DEHGAN
Title or Position: CEO/OWNER
Credential: MD
Phone: 904-247-1919